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. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would the nurse interpret the results?

• A. Respiratory acidosis with no compensation
• B. Metabolic alkalosis with a compensatory alkalosis
• C. Metabolic acidosis with no compensation
• D. Metabolic acidosis with a compensatory respiratory alkalosis

Correct answer: D

Rationale: The given arterial blood gas results show a low pH, indicating acidosis, with normal pH range being 7.35 to 7.45. The low PaCO2 suggests alkalosis, while the low bicarb level indicates acidosis. In this scenario, the primary issue is the metabolic acidosis, as the pH bicarb relationship supports this. The compensatory response to metabolic acidosis is a decrease in PaCO2, leading to a respiratory alkalosis. Therefore, the correct interpretation is 'Metabolic acidosis with a compensatory respiratory alkalosis.' Choices A, B, and C are incorrect as they do not accurately reflect the relationship between the pH, PaCO2, and HCO3 levels in the arterial blood gas results provided.

3. 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.

4. While assessing a patient's peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

• A. Air emboli
• B. Phlebitis
• C. Infiltration
• D. Fluid overload

Correct answer: C

Rationale: Infiltration is the administration of a nonvesicant solution or medication into the surrounding tissue, typically due to the dislodgement or perforation of the vein wall by the IV cannula. It is characterized by edema around the insertion site, leakage of IV fluid, discomfort, coolness, and a decrease in flow rate. In this scenario, the presence of edema indicates infiltration, not air emboli, phlebitis, or fluid overload. Air emboli refer to air bubbles in the bloodstream, phlebitis is inflammation of the vein, and fluid overload is an excessive volume of fluid in the circulatory system.

5. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

• A. Furosemide (Lasix) 40 mg intravenous push
• B. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
• C. Mechanical ventilation
• D. Indwelling urinary catheter

Correct answer: B

Rationale:

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