Nursing Elites

1. The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?

• A. Endocarditis
• B. Multiple myeloma
• C. Guillain-Barr syndrome
• D. Overdose of amphetamines

Correct answer: Guillain-Barr syndrome

Rationale:

2. A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?

• A. The patients calcium will rise dramatically due to pituitary stimulation.
• B. Oxygen will increase the patients intracranial pressure and create confusion.
• C. Oxygen may cause the patient to hyperventilate and become acidotic.
• D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

Correct answer: Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

Rationale:

3. 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.

4. The chief mechanism for maintaining fluid balance is to:

• A. adjust fluid intake so it equals fluid output.
• B. adjust fluid intake so it is slightly above fluid output.
• C. adjust fluid output so it equals fluid input.
• D. adjust fluid intake so it is slightly below fluid output.

Correct answer: C

Rationale: The correct answer is C: 'adjust fluid output so it equals fluid input.' Maintaining fluid balance involves ensuring that the amount of fluid lost through processes like urination, sweating, and respiration equals the amount of fluid taken in. This ensures that the body stays properly hydrated. Choices A, B, and D are incorrect because they do not focus on the balance between fluid input and output, which is crucial for maintaining proper fluid balance. By adjusting fluid output to equal fluid input, the body can regulate hydration levels effectively, preventing dehydration or overhydration.

5. The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?

• A. Respiratory acidosis
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Mixed acidbase disorder

Correct answer: Mixed acidbase disorder

Rationale:

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