Nursing Elites

1. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?

• A. I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup
• B. Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.
• C. It is normal to be a little confused following surgery, and it is safe not to urinate at night.
• D. If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.

Correct answer: Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.

Rationale:

2. After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?

• A. Toasted English muffin with butter and blueberry jam, and tea with sugar
• B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
• C. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
• D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

Correct answer: Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk

Rationale: Choice C is the correct answer as it includes foods high in potassium, such as raisins, whole wheat toast, and milk. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. Choices A, B, and D do not contain significant sources of potassium. Choice A consists mainly of carbohydrates and sugar, choice B focuses on protein and carbohydrates, and choice D provides carbohydrates and some fruit but lacks high-potassium options like in choice C.

3. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would the nurse interpret the results?

• A. Respiratory acidosis with no compensation
• B. Metabolic alkalosis with a compensatory alkalosis
• C. Metabolic acidosis with no compensation
• D. Metabolic acidosis with a compensatory respiratory alkalosis

Correct answer: D

Rationale: The given arterial blood gas results show a low pH, indicating acidosis, with normal pH range being 7.35 to 7.45. The low PaCO2 suggests alkalosis, while the low bicarb level indicates acidosis. In this scenario, the primary issue is the metabolic acidosis, as the pH bicarb relationship supports this. The compensatory response to metabolic acidosis is a decrease in PaCO2, leading to a respiratory alkalosis. Therefore, the correct interpretation is 'Metabolic acidosis with a compensatory respiratory alkalosis.' Choices A, B, and C are incorrect as they do not accurately reflect the relationship between the pH, PaCO2, and HCO3 levels in the arterial blood gas results provided.

4. Which negative ion is most important in intracellular fluid?

• A. Phosphate ions.
• B. Protein molecules.
• C. Chlorine.
• D. Phosphate ions and protein molecules.

Correct answer: D

Rationale: Intracellular fluid contains phosphate ions and protein molecules as essential anions. Phosphate ions play a crucial role in various cellular processes, including energy transfer. Proteins, being large molecules with negative charges, also contribute significantly to the negative ion concentration within cells. Chlorine is primarily an extracellular anion and is not as prominent as phosphate ions and proteins within intracellular fluid, making it a less important negative ion in this context. Therefore, the correct answer is D because both phosphate ions and protein molecules are crucial negative ions in intracellular fluid.

5. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?

• A. Place the patient in low Fowler's position and notify the physician.
• B. Increase the patient's IV fluid and auscultate the lungs.
• C. Place the patient in semi-Fowler's position and prepare to give the PRN diuretic as ordered.
• D. Discontinue the patient's IV.

Correct answer: C

Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.

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