Nursing Elites

1. 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.

2. A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

• A. Assign the patient to a room near the nurse’s station.
• B. Place the patient in a room nearest to the water fountain.
• C. Place the patient on telemetry to monitor for peaked T waves.
• D. Assign the patient to a semi-private room and place an order for a low-salt diet.

Correct answer: A

Rationale: The correct answer is A. The patient should be placed near the nurse’s station if confused to allow close monitoring by the staff. To help improve serum sodium levels, water intake is restricted, so a patient with hyponatremia should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia, so telemetry for this purpose is unnecessary. Placing a confused patient in a semi-private room could be disruptive to the other patient. Additionally, the patient needs sodium replacement, not a low-salt diet.

3. IV potassium chloride (KCl) 60 mEq is prescribed for the treatment of a patient with severe hypokalemia. Which action should the nurse take?

• A. Administer the KCl as a rapid IV bolus.
• B. Infuse the KCl at a rate of 10 mEq/hour.
• C. Only give the KCl through a central venous line.
• D. Discontinue cardiac monitoring during the infusion.

Correct answer: B

Rationale: The correct action for the nurse to take is to infuse the KCl at a rate of 10 mEq/hour. Rapid IV infusion of KCl can lead to cardiac arrest due to its potential for causing hyperkalemia. While KCl can be administered through peripheral veins, central venous lines are not necessary unless specified. It is crucial to continue cardiac monitoring during potassium infusion to promptly identify and manage any potential dysrhythmias that may occur.

4. 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.

5. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

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

Correct answer: A

Rationale: The patient's pH is below the normal range (7.35-7.45), and the HCO3 is also below the normal range (22-26 mEq/L), indicating an acidic environment, which is consistent with metabolic acidosis. The ABGs provided do not support respiratory acidosis or alkalosis, as the PaCO2 is within the normal range (35-45 mm Hg) despite the patient's deep, rapid respirations. Therefore, the correct interpretation is metabolic acidosis.

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