Nursing Elites

1. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?

• A. Diarrhea and vomiting for 36 hours
• B. . Anxiety-induced hyperventilation
• C. Chronic obstructive pulmonary disease (COPD)
• D. Diabetic ketoacidosis and emphysema

Correct answer: B

Rationale:

2. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?

• A. Place the patient in low Fowler's position and notify the physician.
• B. Increase the patient's IV fluid and auscultate the lungs.
• C. Place the patient in semi-Fowler's position and prepare to give the PRN diuretic as ordered.
• D. Discontinue the patient's IV.

Correct answer: C

Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.

3. You are making initial shift assessments on your patients. While assessing one patients 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:

4. A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right uppe

• A. Notify the health care provider
• B. . Administer the prescribed medication.
• C. Discontinue the PICC
• D. Switch the medication to the oral route

Correct answer: B

Rationale:

5. A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?

• A. Tell the patient to rest more often.
• B. Tell the patient to stop taking the digoxin and call the physician.
• C. Call the physician, report the symptoms, and request to draw a blood sample to determine the patient's potassium level.
• D. Tell the patient to avoid foods that contain caffeine.

Correct answer: C

Rationale: The correct action for the nurse to take is to call the physician, report the symptoms, and request to draw a blood sample to determine the patient's potassium level. Furosemide is a potassium-wasting diuretic, and low potassium levels can lead to weakness and palpitations. Resting more often won't address the underlying issue of hypokalemia caused by furosemide. While digoxin can have side effects, it is not causing the symptoms described by the patient. Avoiding caffeine may be beneficial, but addressing the potassium level is more critical in this situation.

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