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. 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: Guillain-Barr syndrome

Rationale:

3. You are working on a burns unit, and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

• A. Metabolic alkalosis
• B. Hypermagnesemia
• C. Hypercalcemia
• D. Hypovolemia

Correct answer: D

Rationale: When a patient exhibits signs and symptoms of third-spacing, where fluid moves out of the intravascular space but not into the intracellular space, hypovolemia is expected. This leads to a decreased circulating blood volume. Increased calcium and magnesium levels are not typically associated with third-spacing fluid shift. Burns usually result in acidosis rather than alkalosis, making metabolic alkalosis an incorrect choice. Therefore, hypovolemia is the correct answer in this scenario.

4. What is the main force that pushes fluid in blood capillaries?

• A. Blood pressure.
• B. Sodium in the blood plasma.
• C. Sodium in the interstitial fluid.
• D. Protein in the blood plasma.

Correct answer: A

Rationale: The correct answer is A, blood pressure. Blood pressure is the primary force that pushes fluid out of the capillaries into the surrounding tissues. This pressure difference is essential for the exchange of nutrients, gases, and waste products between the blood and tissues. Choices B, C, and D are incorrect as they do not represent the primary force responsible for pushing fluid in blood capillaries.

5. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that do mot apply.)

• A. Electrocardiogram changes
• B. Slow, shallow respirations
• C. Paralytic ileus
• D. Skeletal muscle weakness

Correct answer: Slow, shallow respirations

Rationale:

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