Nursing Elites

1. A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

• A. Arterial blood pH is 7.32.
• B. Serum calcium is 18 mg/dL.
• C. Serum potassium is 5.1 mEq/L
• D. Arterial oxygen saturation is 91%.

Correct answer: B

Rationale: The correct answer is B. A serum calcium level of 18 mg/dL is significantly elevated, posing a high risk for cardiac dysrhythmias. Immediate action is required to initiate cardiac monitoring and notify the healthcare provider. While the abnormalities in arterial blood pH, serum potassium, and arterial oxygen saturation also need attention, they are not as immediately life-threatening as the critically high serum calcium level. Therefore, addressing the serum calcium level takes precedence in this scenario.

2. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? (Select all that apply).

• A. Tops of the ears
• B. Bridge of the nose
• C. Around the nostrils
• D. Over the cheeks

Correct answer: C

Rationale: The correct answer is C: 'Around the nostrils.' Constant pressure from the tubing may create skin damage to the areas of skin and bony prominences the nasal cannula will be resting on, including around the nostrils. Choice A, 'Tops of the ears,' is incorrect as the cannula does not rest on the ears. Choice B, 'Bridge of the nose,' is incorrect because the cannula typically rests under the nose. Choice D, 'Over the cheeks,' is also incorrect as the cannula does not typically rest on the cheeks.

3. A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

• A. Discontinue the nasogastric suction.
• B. Give the patient the PRN IV morphine sulfate 4 mg.
• C. Notify the health care provider about the ABG results.
• D. Teach the patient how to take slow, deep breaths when anxious.

Correct answer: B

Rationale: The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.

4. The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

• A. Oral temperature of 100.1°F
• B. Serum sodium level of 138 mEq/L (138 mmol/L)
• C. Gradually decreasing level of consciousness (LOC)
• D. Weight gain of 2 pounds (1 kg) above the admission weight

Correct answer: C

Rationale: The priority assessment finding for the nurse to report to the healthcare provider is a gradually decreasing level of consciousness (LOC). This change in LOC could indicate fluid and electrolyte disturbances, which require immediate attention to prevent complications. While the other options such as an elevated temperature, serum sodium level, and weight gain are important to note and report, they do not indicate an urgent need for intervention compared to changes in LOC which could signify serious issues that need prompt evaluation and management.

5. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

• A. Infuse 5% dextrose in water at 125 mL/hr.
• B. Administer IV morphine sulfate 4 mg every 2 hours PRN.
• C. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
• D. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

Correct answer: A

Rationale: The nurse should question the prescription to infuse 5% dextrose in water at 125 mL/hr because the patient's gastric suction has been depleting electrolytes, leading to hyponatremia. Therefore, the IV solution should include electrolyte replacement. Solutions like lactated Ringer’s solution would usually be ordered. The other choices (B, C, and D) are appropriate for a postoperative patient with gastric suction, addressing pain management, nausea control, and correcting hyponatremia if it drops below a certain level.

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