Nursing Elites

1. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?

• A. . Apply oxygen by mask or nasal cannula
• B. Apply a paper bag over the clients nose and mouth.
• C. Administer 50 mL of sodium bicarbonate intravenously.
• D. Administer 50 mL of 20% glucose and 20 units of regular insulin.

Correct answer: A

Rationale:

2. The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?

• A. Hypermagnesemia
• B. Hyponatremia
• C. Hypocalcemia
• D. Hyperkalemia

Correct answer: C

Rationale:

3. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?

• A. Do you take any over-the-counter medications?
• B. You appear anxious. What is causing your distress?
• C. Do you have a history of anxiety attacks?
• D. You are breathing fast. Is this causing you to feel light-headed?

Correct answer: B

Rationale:

4. When considering overhydration:

• A. occurs less often than dehydration.
• B. can strain the kidneys.
• C. can be caused by giving intravenous fluids too rapidly.
• D. less common than dehydration.

Correct answer: C

Rationale: The correct answer is C. Overhydration can occur when intravenous fluids are administered too quickly, overwhelming the body's ability to excrete the excess fluid. Choices A, B, and D are incorrect. Choice A is incorrect because overhydration is less common than dehydration. Choice B is incorrect because while overhydration can strain the kidneys, it is not due to the burden being too heavy. Choice D is incorrect because dehydration is more common than overhydration.

5. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that do not apply.)

• A. Hypokalemia Flaccid paralysis with respiratory depression
• B. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
• C. . Hyponatremia Decreased level of consciousness
• D.

Correct answer: B

Rationale:

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