Nursing Elites

1. The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?

• A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
• B. Observe for swelling of the neck, tracheal deviation, and severe pain.
• C. Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
• D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Correct answer: D

Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. Monitoring for an elevated thyroid-stimulating hormone (choice A) is not relevant in assessing for hypocalcemia. Observing for swelling of the neck, tracheal deviation, and severe pain (choice B) are more related to airway compromise. Evaluating the quality of the patient's voice postoperatively (choice C) is important but not a primary sign of hypocalcemia.

2. What would be the best initial nursing action prior to inserting an IV?

• A. Instruct the patient to wash their hands.
• B. Prepare the IV insertion site with povidone iodine.
• C. Verify the order for IV therapy.
• D. Identify a suitable vein.

Correct answer: C

Rationale: The best initial nursing action prior to inserting an IV is to verify the order for IV therapy. This step ensures that the IV insertion is appropriate and necessary based on the physician's orders. Instructing the patient to wash their hands (Choice A) is important for infection control but not the immediate priority before IV insertion. While preparing the IV insertion site with povidone iodine (Choice B) and identifying a suitable vein (Choice D) are crucial steps in the process, confirming the order for IV therapy (Choice C) takes precedence to ensure the correct intervention is being performed.

3. You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?

• A. Hypocalcemia
• B. Hyponatremia
• C. Hyperchloremia
• D. Hypophosphatemia

Correct answer: C

Rationale:

4. A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?

• A. Allergic reaction
• B. Bowel obstruction
• C. Catheter lumen occlusion
• D. Infection

Correct answer: D

Rationale:

5. A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

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

Correct answer: A

Rationale:

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