Nursing Elites

1. The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?

• A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
• B. Observe for swelling of the neck, tracheal deviation, and severe pain.
• C. Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
• D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Correct answer: D

Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. Monitoring for an elevated thyroid-stimulating hormone (choice A) is not relevant in assessing for hypocalcemia. Observing for swelling of the neck, tracheal deviation, and severe pain (choice B) are more related to airway compromise. Evaluating the quality of the patient's voice postoperatively (choice C) is important but not a primary sign of hypocalcemia.

2. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems?

• A. Diminished deep tendon reflexes
• B. Tachycardia
• C. Cool, clammy skin
• D. Acute flank pain

Correct answer: A

Rationale: Corrected Rationale: To assess a patient's magnesium status, the nurse should check deep tendon reflexes. Diminished deep tendon reflexes may indicate high serum magnesium levels, as hypermagnesemia can lead to neuromuscular effects. Tachycardia, cool clammy skin, and acute flank pain are not typically associated with high magnesium levels and are not priority assessments in this situation.

3. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

• A. Furosemide (Lasix) 40 mg intravenous push
• B. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
• C. Mechanical ventilation
• D. Indwelling urinary catheter

Correct answer: B

Rationale:

4. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values?

• A. . Diabetic ketoacidosis in a person with emphysema
• B. Bronchial obstruction related to aspiration of a hot dog
• C. Anxiety-induced hyperventilation in an adolescen
• D. Diarrhea for 36 hours in an older, frail woman

Correct answer: A

Rationale:

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.

Similar Questions