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: C

Rationale:

2. 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.

3. You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly?

• A. Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly.
• B. Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.
• C. Malnourished patients who receive fluids too rapidly are at risk for hypernatremia.
• D. Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate

Correct answer: B

Rationale:

4. Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?

• A. Diminished deep tendon reflexes
• B. Tachycardia
• C. Cool clammy skin
• D. Increased serum magnesium

Correct answer: A

Rationale: The correct answer is A: Diminished deep tendon reflexes. In a patient with hypermagnesemia, the nurse would assess for diminished deep tendon reflexes. Hypermagnesemia can lead to neuromuscular depression, causing a decrease in deep tendon reflexes. Tachycardia (choice B) is more commonly associated with hypomagnesemia. Cool clammy skin (choice C) is not typically a direct symptom of hypermagnesemia. While hypermagnesemia does involve increased serum magnesium levels (choice D), assessing serum levels is a laboratory test and not a clinical assessment like checking deep tendon reflexes.

5. Which substance dissociates into ions in a water solution?

• A. Intracellular fluid
• B. Interstitial fluid
• C. Plasma
• D. Electrolyte

Correct answer: D

Rationale: The correct answer is 'Electrolyte.' Electrolytes are substances that dissociate into ions when dissolved in water. Intracellular fluid, interstitial fluid, and plasma are not substances that dissociate into ions in a water solution. Intracellular fluid is the fluid inside cells, interstitial fluid is the fluid between cells, and plasma is the liquid component of blood. These choices do not dissociate into ions in a water solution, unlike electrolytes.

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