Nursing Elites

1. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Increased PaCO2
• D. CNS disturbances

Correct answer: B

Rationale:

2. A nurse is assessing a client with hypokalemia and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?

• A. Assess the client's respiratory rate, rhythm, and depth.
• B. Measure the client's pulse and blood pressure.
• C. Document findings and monitor the client.
• D. Call the healthcare provider.

Correct answer: A

Rationale: In a client with hypokalemia experiencing diminished handgrip strength, the priority action for the nurse is to assess the client's respiratory rate, rhythm, and depth. Hypokalemia can lead to muscle weakness, including respiratory muscles, potentially causing respiratory distress. Assessing the respiratory status is crucial to determine if immediate interventions are needed to maintain adequate oxygenation. Measuring the client's pulse and blood pressure (Choice B) is important but should come after assessing the respiratory status. Simply documenting findings and monitoring the client (Choice C) may delay necessary interventions. Calling the healthcare provider (Choice D) is not the first action indicated in this situation; assessing the client's respiratory status takes precedence.

3. Which electrolyte is important in the formation of the thyroid hormones?

• A. Sodium
• B. Iodine
• C. Iron
• D. Chloride

Correct answer: B

Rationale: Iodine is the correct answer because it is essential for the synthesis of thyroid hormones. The thyroid gland incorporates iodine into thyroid hormones such as thyroxine (T4) and triiodothyronine (T3). These hormones are crucial for regulating metabolism, growth, and development. Sodium, iron, and chloride are not directly involved in the formation of thyroid hormones, making them incorrect choices.

4. Which of the following statements is correct?

• A. People with less body fat have more body water.
• B. Infants have more water per pound than adults.
• C. Females have more body water per pound than males.
• D. Infants have the same water content per pound as adults.

Correct answer: A

Rationale: The correct statement is that people with less body fat have more body water. This is because fat tissue contains less water compared to lean tissue, so individuals with less body fat generally have a higher percentage of body water. Choice B is incorrect as infants actually have more water per pound than adults due to their higher body water content. Choice C is incorrect as males typically have more body water per pound than females. Choice D is incorrect as infants have a higher water content per pound compared to adults.

5. A 65-year-old male patient was admitted to a medical-surgical unit 72 hours ago with pyloric stenosis; a nasogastric tube was inserted upon admission and has been on low intermittent suction since then. The nurse taking care of the patient notices that his potassium is very low and becomes concerned that the patient may be at risk for:

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

Correct answer: C

Rationale: The correct answer is C, metabolic alkalosis. The patient with pyloric stenosis has been on low intermittent suction, leading to the loss of hydrogen and chloride ions. This condition causes metabolic alkalosis due to the removal of these ions. Options A (Hypercalcemia) and D (Respiratory acidosis) are incorrect as they are not directly related to the scenario described. Option B (Metabolic acidosis) is also incorrect; in this case, the patient is at risk of metabolic alkalosis due to the loss of hydrogen and chloride ions through gastric suction.

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