Nursing Elites

1. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

• A. Furosemide (Lasix) 40 mg intravenous push
• B. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
• C. Mechanical ventilation
• D. Indwelling urinary catheter

Correct answer: B

Rationale:

2. When does dehydration begin to occur?

• A. the body reduces fluid output to zero.
• B. the body increases the release of ANH.
• C. the salivary secretions decrease.
• D. the salivary secretions increase.

Correct answer: C

Rationale: Dehydration leads to a decrease in the body's fluid levels, causing the salivary glands to produce less saliva, resulting in a dry mouth. Therefore, when dehydration begins to occur, salivary secretions decrease. Choice A is incorrect because the body does not reduce fluid output to zero during dehydration; it tries to conserve fluids. Choice B is incorrect as dehydration does not directly increase the release of ANH (Atrial Natriuretic Hormone). Choice D is incorrect because salivary secretions do not increase but decrease during dehydration.

3. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

• A. Leave one hand ungloved to assess the site.
• B. Cleanse the skin with normal saline.
• C. Ask the patient about allergies to latex or iodine.
• D. Remove excessive hair from the selected site.

Correct answer: C

Rationale:

4. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?

• A. Air emboli
• B. Phlebitis
• C. Infiltration
• D. Fluid overload

Correct answer: C

Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the vein's wall. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort, and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli (Choice A) involves air entering the bloodstream. Phlebitis (Choice B) is inflammation of a vein. Fluid overload (Choice D) is an excessive volume of fluid in the circulatory system.

5. You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?

• A. Respiratory acidosis with no compensation
• B. Metabolic alkalosis with a compensatory alkalosis
• C. Metabolic acidosis with no compensation
• D. Metabolic acidosis with a compensatory respiratory alkalosis

Correct answer: D

Rationale:

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