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 client with a serum potassium of 7.5 mEq/L and cardiovascular changes needs immediate intervention. Which prescription should the nurse implement first?

• A. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
• B. Provide a heart-healthy, low-potassium diet.
• C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
• D. Prepare the client for hemodialysis treatment.

Correct answer: C

Rationale: In a client with a serum potassium level of 7.5 mEq/L and cardiovascular changes, the priority intervention is to lower the potassium level quickly to prevent life-threatening complications like arrhythmias. The correct answer is to prepare to administer dextrose 20% and 10 units of regular insulin IV push. This combination helps shift potassium from the extracellular to the intracellular space, reducing serum potassium levels rapidly. Administering sodium polystyrene sulfate (Kayexalate) by mouth may take several hours to work, making it a less effective immediate intervention. Providing a heart-healthy, low-potassium diet is important for long-term management but is not the most urgent action in this situation. While hemodialysis is a definitive treatment for hyperkalemia, it is not the first-line intervention for acute management of high potassium levels with cardiovascular manifestations.

3. What is the fluid that surrounds the cells called?

• A. plasma
• B. interstitial fluid
• C. intracellular fluid
• D. edema

Correct answer: B

Rationale: The correct answer is interstitial fluid. Interstitial fluid is the fluid that surrounds and fills the spaces between cells, facilitating nutrient and waste exchange. Plasma, referred to in choice A, is the liquid part of blood. Choice C, intracellular fluid, is the fluid inside cells. Choice D, edema, is an abnormal accumulation of fluid in interstitial spaces, causing swelling.

4. What is the most important regulator of the amount of sodium in the body?

• A. Kidneys
• B. Small intestine
• C. Large intestine
• D. Skin

Correct answer: A

Rationale: The correct answer is A: Kidneys. The kidneys play a crucial role in regulating the amount of sodium in the body. They achieve this by filtering blood and controlling the excretion or reabsorption of sodium. The small intestine is primarily responsible for nutrient absorption, not sodium regulation. The large intestine is mainly involved in water absorption and waste elimination, not sodium balance. The skin helps regulate body temperature through sweating and does not directly regulate sodium levels.

5. Your patient has alcoholism, and you may suspect during your assessment that his serum magnesium is low. What will the nurse potentially expect to assess related to hypomagnesemia?

• A. Tremor
• B. Pruritus
• C. Edema
• D. Decreased blood pressure

Correct answer: A

Rationale: The correct answer is A: Tremor. Signs and symptoms of hypomagnesemia primarily affect the neuromuscular system and can include tremors, confusion, tetany, laryngeal stridor, and ataxia. Pruritus (choice B) refers to itching and is not typically associated with hypomagnesemia. Edema (choice C) is swelling caused by fluid retention and is not a common manifestation of hypomagnesemia. Decreased blood pressure (choice D) is not a typical sign of hypomagnesemia; instead, low magnesium levels are more likely to cause hypertension.

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