Nursing Elites

1. How should the nurse interpret the following arterial blood gas results for a patient who had a tracheostomy placed after a motor vehicle crash: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: D

Rationale: The patient's pH of 7.48 indicates alkalosis, and the low PaCO2 of 32 mm Hg suggests a respiratory cause. The HCO3 level is normal, ruling out metabolic causes. Therefore, the correct interpretation is respiratory alkalosis. Options A, B, and C are incorrect as they do not align with the pH and PaCO2 values provided.

2. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

• A. Tie the knot with a double turn or square knot
• B. Ensure that the restraints are snug against the client's wrists
• C. Ensure that the knot can be quickly released
• D. Move the ties so the restraints are secured to the side rails

Correct answer: C

Rationale: The priority is to ensure that the knot can be quickly released to allow for quick intervention if necessary. Tying the knot with a double turn or square knot (Choice A) may make it more difficult to release quickly in an emergency. Ensuring that the restraints are snug against the client's wrists (Choice B) may compromise circulation and cause discomfort. Moving the ties to secure the restraints to the side rails (Choice D) is not the appropriate action as it can limit the client's movement and access to care.

3. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

• A. red and edematous stoma appearance
• B. liquid brown drainage from stoma
• C. stoma output of 40ml in the last hour
• D. mucous strings floating in the drainage

Correct answer: C

Rationale: Stoma output of only 40ml in the last hour may indicate a problem, such as dehydration or blockage, and should be reported immediately. A red and edematous stoma appearance could be due to inflammation, which is expected in the early postoperative period. Liquid brown drainage from the stoma is a normal finding. Mucous strings floating in the drainage are also a common occurrence postoperatively and do not typically require immediate reporting.

4. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

• A. Blood pressure is 90/40 mm Hg.
• B. Urine output is 30 mL over the last hour.
• C. Oral fluid intake is 100 mL over the last 8 hours.
• D. There is prolonged skin tenting over the sternum.

Correct answer: A

Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.

5. The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

• A. Increase fluids if your mouth feels dry.
• B. More fluids are needed if you feel thirsty.
• C. Drink more fluids in the late evening hours.
• D. If you feel lethargic or confused, you need more to drink.

Correct answer: A

Rationale: The correct answer is A. An alert, older patient can self-assess for signs of dehydration like dry mouth. This instruction is appropriate as it encourages the patient to respond to early signs of dehydration. Choice B is incorrect because the thirst mechanism decreases with age and feeling thirsty may not accurately indicate the need for fluids. Choice C is incorrect as many older patients prefer to limit evening fluid intake to enhance sleep quality. Choice D is incorrect because an older adult who is lethargic or confused may not be able to accurately assess their need for fluids.

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