Nursing Elites

1. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?

• A. Agitation
• B. Kussmaul respirations
• C. Seizures
• D. Positive Chvosteks sign

Correct answer: B

Rationale:

2. The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?

• A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
• B. Observe for swelling of the neck, tracheal deviation, and severe pain.
• C. Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
• D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Correct answer: D

Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. Monitoring for an elevated thyroid-stimulating hormone (choice A) is not relevant in assessing for hypocalcemia. Observing for swelling of the neck, tracheal deviation, and severe pain (choice B) are more related to airway compromise. Evaluating the quality of the patient's voice postoperatively (choice C) is important but not a primary sign of hypocalcemia.

3. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:

• A. Choose a proximal site.
• B. Choose a distal site.
• C. Have the patient hold their arm in a dependent position.
• D. Leave the tourniquet on for no longer than 2 minutes.

Correct answer: B

Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Opting for a distal site ensures that upper veins remain available for future cannulations. Instructing the patient to hold their arm in a dependent position can enhance blood flow, aiding in the procedure. It is crucial never to leave a tourniquet on for more than 2 minutes as prolonged restriction can lead to complications. Choice A is incorrect because a proximal site is not preferred for IV insertion. Choice C is incorrect as having the patient hold their arm over their head is not necessary and may impede proper blood flow. Choice D is incorrect as leaving the tourniquet on for at least 5 minutes is excessive and can be harmful.

4. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

• A. Assess clients rate, rhythm, and depth of respiration.
• B. Measure the clients pulse and blood pressure.
• C. Document the findings and continue to monitor.
• D. Notify the physician as soon as possible.

Correct answer: A

Rationale:

5. The healthcare professional working in the PACU is aware that which of the following procedures may contribute to extracellular losses?

• A. Removal of an ingrown toenail
• B. Tooth extraction
• C. Abdominal surgery
• D. Cataract surgery

Correct answer: C

Rationale: Fluid loss from the extracellular compartment can be caused by abdominal surgery as it involves opening the abdominal cavity, potentially leading to significant fluid losses. Choices A, B, and D do not typically result in substantial extracellular losses compared to abdominal surgery.

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