Nursing Elites

1. The nurse in the intensive care unit receives arterial blood gases (ABG) with a patient who is complaining of being 'short of breath.' The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mmol/L. The labs reflect:

• A. Respiratory acidosis
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Metabolic acidosis

Correct answer: A

Rationale: The ABG values indicate respiratory acidosis. A pH below 7.40, a PaCO2 above 40 mm Hg, and a normal HCO3 level (24 mmol/L) suggest respiratory acidosis. In this case, the patient has an acidic pH (7.21) and an elevated PaCO2 (64 mm Hg), indicating inadequate ventilation. The normal HCO3 level suggests that compensation by the kidneys has not occurred, implying an acute event. Choices B, C, and D can be ruled out based on the given ABG values and the criteria for acid-base disorders.

2. Which of the following organs does not contribute to fluid output from the body?

• A. Lungs
• B. Skin
• C. Intestine
• D. Lungs, skin, and intestine

Correct answer: D

Rationale: The correct answer is D. All the listed organs (lungs, skin, and intestines) contribute to fluid loss from the body. Lungs contribute to fluid loss through respiration, skin through sweating, and intestines through excretion. Therefore, none of the organs listed in the options retain fluids within the body. Choices A, B, and C are incorrect because all of these organs play a role in fluid output from the body.

3. When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?

• A. Active transport of hydrogen ions across the capillary walls
• B. Pressure of the blood in the renal capillaries
• C. Action of the dissolved particles contained in a unit of blood
• D. Hydrostatic pressure resulting from the pumping action of the heart

Correct answer: D

Rationale:

4. A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

• A. Administer a sublingual nitroglycerin tablet
• B. Prepare to assist with chest tube insertion.
• C. . Place a sterile dressing over the IV site
• D. Re-position the client into the Trendelenburg position.

Correct answer: B

Rationale:

5. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems?

• A. Diminished deep tendon reflexes
• B. Tachycardia
• C. Cool, clammy skin
• D. Acute flank pain

Correct answer: A

Rationale: Corrected Rationale: To assess a patient's magnesium status, the nurse should check deep tendon reflexes. Diminished deep tendon reflexes may indicate high serum magnesium levels, as hypermagnesemia can lead to neuromuscular effects. Tachycardia, cool clammy skin, and acute flank pain are not typically associated with high magnesium levels and are not priority assessments in this situation.

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