Nursing Elites

1. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor?

• A. Overhydration is common among healthy older adults.
• B. Dehydration causes the skin to appear spongy.
• C. Inelastic skin turgor is a normal part of aging.
• D. Skin turgor cannot be assessed in patients over 70.

Correct answer: C

Rationale: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Choice A is incorrect because overhydration is not common among healthy older adults. Choice B is incorrect because dehydration leads to inelastic skin, not sponginess. Choice D is incorrect as skin turgor assessment can be done in patients of any age, including those over 70.

2. What electrolyte value should be monitored when a patient is receiving a loop diuretic?

• A. Calcium levels
• B. Phosphorus levels
• C. Potassium levels
• D. Magnesium levels

Correct answer: C

Rationale: When a patient is receiving a loop diuretic like furosemide (Lasix), potassium levels should be monitored closely. Loop diuretics act on the ascending loop of Henle to inhibit the reabsorption of sodium and water, leading to potassium loss. Monitoring potassium levels is crucial to prevent hypokalemia, which can result in serious complications such as cardiac arrhythmias. Calcium levels (Choice A), phosphorus levels (Choice B), and magnesium levels (Choice D) are not typically affected directly by loop diuretics and do not require routine monitoring in this context.

3. When preparing a site for the insertion of an IV catheter, how should excess hair at the site be treated?

• A. Leaving the hair intact
• B. Shaving the area
• C. Clipping the hair in the area
• D. Removing the hair with a depilatory

Correct answer: C

Rationale: The correct answer is to clip the hair in the area. Excess hair at the site of IV catheter insertion should be removed because it can be a potential source of infection. Clipping the hair is preferred over shaving because shaving can cause skin abrasions, increasing the risk of infection. Using depilatories is not recommended as they can irritate the skin, which is undesirable when preparing a clean site for an invasive procedure. Therefore, clipping the hair in the area is the most appropriate and safe method to prepare the site for IV catheter insertion.

4. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.)

• A. Use a draw sheet to reposition the client in bed.
• B. . Strain all urine output and assess for urinary stones.
• C. Provide nonslip footwear for the client to use when out of bed.
• D.

Correct answer: B

Rationale:

5. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand, and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

• A. Hypophosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hyperkalemia

Correct answer: B

Rationale: The symptoms described, including tingling in the lips and fingers, intermittent spasms, and increased muscle tone, are indicative of tetany, which is a common manifestation of hypocalcemia. Hypocalcemia can lead to neuromuscular irritability, causing symptoms such as paresthesias and muscle spasms. Hypophosphatemia primarily affects the central nervous system, resulting in seizures and coma. Hypermagnesemia typically presents with hypoactive reflexes and somnolence. Hyperkalemia can cause paresthesias and anxiety, but in this case, the patient's symptoms are more suggestive of hypocalcemia.

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