Nursing Elites

1. The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?

• A. Cimetidine
• B. Maalox
• C. Potassium chloride elixir
• D. ) Furosemide

Correct answer: A

Rationale:

2. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?

• A. A 34-year-old on NPO status who is receiving intravenous D5W
• B. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
• C. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
• D. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

Correct answer: A

Rationale: The correct answer is the 34-year-old on NPO status receiving intravenous D5W because D5W is a hypotonic solution that can dilute the blood's sodium levels, leading to hyponatremia. Patients on NPO status rely solely on intravenous fluids for hydration, making them more susceptible to electrolyte imbalances. Choices B, C, and D are less likely to cause hyponatremia. Choice B, the 50-year-old with an infection on a sulfonamide antibiotic, is at risk for allergic reactions or renal issues. Choice C, the 67-year-old taking ibuprofen, is at risk for gastrointestinal bleeding or kidney problems. Choice D, the 73-year-old on digoxin with tachycardia, is more likely to experience digoxin toxicity, affecting the heart's rhythm.

3. The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate?

• A. Hypermagnesemia
• B. Hypomagnesemia
• C. Hypocalcemia
• D. Hyperkalemia

Correct answer: C

Rationale: Chvostek's sign is characterized by a brief contraction of the upper lip, nose, or side of the face and is indicative of hypocalcemia, making choice C the correct answer. Hypomagnesemia (choice B) is associated with Trousseau's sign, not Chvostek's sign. Hypermagnesemia (choice A) is not related to Chvostek's sign. Hyperkalemia (choice D) is not typically associated with Chvostek's sign; instead, it may present with muscle weakness and cardiac arrhythmias.

4. Which organ has the greatest effect on fluid output?

• A. Kidneys
• B. Lungs
• C. Skin
• D. Intestines

Correct answer: A

Rationale: The correct answer is the kidneys. The kidneys are primarily responsible for regulating fluid balance by filtering blood and adjusting the volume and concentration of urine. The lungs primarily regulate gas exchange, not fluid balance. The skin plays a role in temperature regulation and protection but is not the primary organ for fluid output. The intestines are mainly involved in the absorption of nutrients and water, rather than fluid output.

5. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

• A. Choose a site with minimal hair if available.
• B. Consider potential effects on the patient's mobility when selecting a site.
• C. Instruct the patient to hold his arm in a dependent position before insertion.
• D. Remove the tourniquet after 2 minutes.

Correct answer: B

Rationale: When selecting a site for IV insertion on the hand or arm, it is important to consider the potential effects on the patient's mobility. The chosen site should not interfere with the patient's movement. Instructing the patient to hold his arm in a dependent position helps increase blood flow, aiding in vein visualization and insertion. It is advisable to choose a site with minimal hair if possible for better adhesion of the dressing. Removing the tourniquet after 2 minutes is recommended to prevent complications like hemoconcentration and potential vein damage. Therefore, option B is the correct choice as it aligns with best practices for IV insertion.

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