Nursing Elites

1. 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:

2. A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

• A. The initial site dressing is 3 days old.
• B. The PICC was inserted 4 weeks ago.
• C. A securement device is absent.
• D. Upper extremity swelling is noted.

Correct answer: D

Rationale:

3. The nurse assessing skin turgor in an elderly patient should remember that:

• A. Overhydration causes the skin to tent.
• B. Dehydration causes the skin to appear edematous and spongy.
• C. Inelastic skin turgor is a normal part of aging.
• D. Normal skin turgor is moist and boggy.

Correct answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.

4. A nurse admitting a patient with a history of emphysema reviews her past lab reports and notes that the patient's PaCO2 has been 56 to 64 mmHg. The nurse will be cautious administering oxygen because:

• A. The patient's calcium will rise dramatically due to pituitary stimulation.
• B. The oxygen will increase the patient's intracranial pressure and create confusion.
• C. The oxygen may cause the patient to hyperventilate and become acidotic.
• D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

Correct answer: D

Rationale: When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. Choice A is incorrect because administering oxygen does not lead to a dramatic rise in calcium due to pituitary stimulation. Choice B is incorrect because administering oxygen does not directly increase intracranial pressure or create confusion. Choice C is incorrect because administering oxygen to a patient with emphysema and high PaCO2 levels is more likely to cause respiratory depression than hyperventilation and acidosis.

5. What can cause dehydration?

• A. Prolonged vomiting.
• B. Prolonged diarrhea.
• C. Too little fluid intake.
• D. Prolonged vomiting, diarrhea, and too little fluid intake.

Correct answer: D

Rationale: Dehydration can result from significant fluid loss due to vomiting, diarrhea, or inadequate fluid intake. Prolonged vomiting and diarrhea lead to excessive fluid loss from the body, contributing to dehydration. Similarly, not consuming enough fluids can also result in dehydration. Choice A and B are too specific as they only mention one cause each, while choice C is also correct but does not encompass all the potential causes of dehydration as mentioned in choice D.

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