Nursing Elites

1. The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

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

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation is the most common cause of acute respiratory alkalosis. When a patient hyperventilates due to anxiety or other causes, they blow off excessive carbon dioxide, leading to a decrease in PaCO2 and a rise in pH. Choices A, C, and D are incorrect because hyperventilation leads to a decrease in PaCO2, causing respiratory alkalosis, not respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

2. A patient with hypokalemia and heart failure is admitted to the telemetry unit. The nurse is aware that hypokalemia could cause which of the following abnormalities on an electrocardiogram (ECG)?

• A. Shortened P-R interval
• B. Inverted T wave
• C. Depressed U wave
• D. Elevated U wave

Correct answer: D

Rationale: The correct answer is D: Elevated U wave. Hypokalemia is associated with ECG changes such as an elevated U wave and flattened T waves. Choice A, a shortened P-R interval, is not typically seen in hypokalemia. Choice B, an inverted T wave, is more commonly associated with ischemia or CNS injury rather than hypokalemia. Choice C, a depressed U wave, is not a typical ECG abnormality seen in hypokalemia. Therefore, the correct ECG abnormality associated with hypokalemia is an elevated U wave.

3. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the followin

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

Correct answer: Diminished deep tendon reflexes

Rationale:

4. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

• A. Leave one hand ungloved to assess the site.
• B. Cleanse the skin with normal saline.
• C. Ask the patient about allergies to latex or iodine.
• D. Remove excessive hair from the selected site.

Correct answer: Ask the patient about allergies to latex or iodine.

Rationale:

5. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

• A. Assess clients rate, rhythm, and depth of respiration.
• B. Measure the clients pulse and blood pressure.
• C. Document the findings and continue to monitor.
• D. Notify the physician as soon as possible.

Correct answer: Assess clients rate, rhythm, and depth of respiration.

Rationale:

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