Nursing Elites

1. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that do not apply.)

• A. A 36-year-old who is malnourished
• B. A 42-year-old with uncontrolled diabetes
• C. A 76-year-old who is prescribed antacids
• D. 50-year-old with hyperparathyroidism

Correct answer: C

Rationale:

2. A 73-year-old man who slipped on a small carpet in his home and fell on his hip is alert and oriented; PERRLA (pupils equally round and reactive to light and accommodation) is intact, and he has come by ambulance to the emergency department (ED). Heart rate elevated, he is anxious and thirsty. A Foley catheter is in place and 40mL of urine is present. The nurse's most likely explanation for the urine output is:

• A. The man urinated prior to his arrival in the ED and will probably not need to have the Foley catheter kept in place.
• B. The man has a brain injury, lacks ADH, and needs vasopressin.
• C. The man is in heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output.
• D. He is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

Correct answer: D

Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely cause of the lower urine output. Choices A, B, and C are incorrect because there is no indication of urination prior to arrival, brain injury, lack of ADH, or heart failure present in the scenario provided. The symptoms and context described point more towards a physiological response related to the sympathetic nervous system and the renin-angiotensin-aldosterone system rather than the other conditions mentioned.

3. The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?

• A. Respiratory acidosis
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Mixed acidbase disorder

Correct answer: D

Rationale:

4. A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:

• A. Neuromuscular function
• B. Bowel sounds
• C. Respiratory rate
• D. Electrocardiogram (ECG) results

Correct answer: D

Rationale: In a patient with a serum potassium level of 6 mEq/L due to spironolactone use, the nurse's priority is to assess the Electrocardiogram (ECG) results. Hyperkalemia can lead to life-threatening arrhythmias, such as ventricular fibrillation, which can be detected on an ECG. While changes in neuromuscular function, bowel sounds, and respiratory rate can occur with hyperkalemia, the most critical assessment related to the patient's condition would be monitoring the ECG for signs of cardiac complications.

5. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health?

• A. Nutritional status
• B. Potassium balance
• C. Calcium balance
• D. Fluid volume status

Correct answer: D

Rationale: Assessing the specific gravity in a patient with SIADH helps the nurse evaluate the patient's fluid volume status. Specific gravity indicates the concentration of solutes in the urine and can detect if the patient has a fluid volume deficit or excess. Nutritional status, potassium balance, and calcium balance are not directly assessed through specific gravity testing. Nutritional status is typically evaluated through dietary intake and anthropometric measurements. Potassium balance is assessed through blood tests and ECG monitoring. Calcium balance is evaluated through blood tests and bone density scans. Therefore, the correct answer is assessing fluid volume status through specific gravity testing.

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