Nursing Elites

1. When considering overhydration:

• A. occurs less often than dehydration.
• B. can strain the kidneys.
• C. can be caused by giving intravenous fluids too rapidly.
• D. less common than dehydration.

Correct answer: C

Rationale: The correct answer is C. Overhydration can occur when intravenous fluids are administered too quickly, overwhelming the body's ability to excrete the excess fluid. Choices A, B, and D are incorrect. Choice A is incorrect because overhydration is less common than dehydration. Choice B is incorrect because while overhydration can strain the kidneys, it is not due to the burden being too heavy. Choice D is incorrect because dehydration is more common than overhydration.

2. The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?

• A. Endocarditis
• B. Multiple myeloma
• C. Guillain-Barr syndrome
• D. Overdose of amphetamines

Correct answer: C

Rationale:

3. During a visit to an 84-year-old woman recovering from hip surgery, the nurse notices signs of confusion and poor skin turgor. The woman mentions she limits water intake to avoid nighttime bathroom trips. The nurse should explain to the woman that:

• A. She will need her medications adjusted and be readmitted for a complete workup.
• B. Limiting fluids can lead to body imbalances causing confusion; perhaps adjusting fluid intake timing is necessary.
• C. Post-surgical confusion is common, and it's safe not to urinate at night.
• D. Confusion after surgery is typical in the elderly due to sleep loss.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid and electrolyte imbalances can manifest with subtle signs like confusion. Limiting fluids can lead to such imbalances, affecting cognitive function. Adjusting the timing of fluid intake can help maintain hydration without causing nighttime disruptions. Choices A, C, and D are incorrect. Choice A suggests unnecessary hospital readmission and medication adjustments without addressing the root cause. Choice C wrongly normalizes the confusion and fails to address the potential issue of fluid restriction. Choice D incorrectly attributes confusion solely to sleep loss without considering the impact of fluid balance.

4. The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit

• A. Diarrhea
• B. Dilute urine
• C. Increased muscle tone
• D. Joint pain

Correct answer: B

Rationale:

5. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?

• A. Depth of respirations
• B. Bowel sounds
• C. Grip strength
• D. Electrocardiography

Correct answer: A

Rationale: The correct answer is 'Depth of respirations.' In a client with electrolyte imbalances like low potassium (hypokalemia) and low magnesium (hypomagnesemia), respiratory changes, such as shallow respirations or respiratory muscle weakness, can occur and lead to respiratory compromise. Assessing the depth of respirations is crucial to evaluate respiratory function in this client. Bowel sounds, grip strength, and electrocardiography are also important assessments in different situations, but in this case, respiratory assessment takes priority due to the potential impact of electrolyte imbalances on breathing.

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