Nursing Elites

1. Which of the following is a sign of hypocalcemia?

• A. Hyperactive reflexes.
• B. Depressed reflexes.
• C. Muscle cramps.
• D. Seizures.

Correct answer: A

Rationale: Hyperactive reflexes are a classic sign of hypocalcemia. Hypocalcemia leads to increased neuromuscular excitability, resulting in hyperactive reflexes. Depressed reflexes (Choice B) are not typically associated with hypocalcemia. Muscle cramps (Choice C) can be seen in hypocalcemia due to muscle irritability but are not a specific sign. Seizures (Choice D) can occur in severe cases of hypocalcemia but are not as common as hyperactive reflexes.

2. An older female client has normal saline infusing at 45 mL/hour. She complains of pain at the insertion site of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?

• A. Determine which IV medications have recently been administered.
• B. Explain that without redness or edema, there is no need to re-start the IV.
• C. Consult with the healthcare provider about the best location to start a new IV.
• D. Convert the IV to a saline lock and continue to monitor the site.

Correct answer: D

Rationale: Converting the IV to a saline lock and continuing to monitor the site is the correct action in this scenario. When a client complains of pain at the IV insertion site without redness or edema, it may indicate phlebitis or irritation. Replacing the IV may not be necessary if there are no signs of infection or infiltration. Determining the IV medications administered or consulting with the healthcare provider to start a new IV are not immediate actions required for pain management at the insertion site. Therefore, the most appropriate intervention is to convert the IV to a saline lock and closely observe for any changes or complications.

3. A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse?

• A. The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.
• B. The triglycerides are elevated and will not return to normal without these medications.
• C. The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed.
• D. These medications will reduce the risk of type 2 diabetes.

Correct answer: C

Rationale: CRP is a marker of inflammation, which is elevated in cardiovascular disease. Statins and aspirin help lower CRP and reduce the risk of heart attacks and strokes.

4. A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min via nasal cannula. What should the nurse do next?

• A. Call for the physician.
• B. Start an IV infusion.
• C. Obtain a portable chest radiograph.
• D. Draw blood for laboratory studies.

Correct answer: B

Rationale: In a client presenting with possible myocardial infarction who is receiving oxygen therapy and cardiac monitoring, the next priority action is to establish IV access by starting an IV infusion. This allows for prompt administration of medications and fluids as needed in the management of acute coronary syndromes. Calling the physician (Choice A) may be necessary but is not the immediate next step. Obtaining a portable chest radiograph (Choice C) may help in further assessment but is not as crucial as establishing IV access. Drawing blood for laboratory studies (Choice D) is important for diagnostic purposes but is not as urgent compared to starting an IV infusion in the setting of a potential myocardial infarction.

5. When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?

• A. Aching pain in the left calf.
• B. Burning pain in the left calf.
• C. Numbness and tingling in the left leg.
• D. Coldness of the left foot and ankle.

Correct answer: D

Rationale: Coldness of the left foot and ankle is the correct clinical manifestation indicating complete arterial obstruction in the lower left leg. Complete arterial obstruction results in reduced blood flow, leading to decreased temperature in the affected area. Aching pain (Choice A) and burning pain (Choice B) are more commonly associated with partial obstructions or ischemia, while numbness and tingling (Choice C) can be indicative of nerve involvement or compromised circulation, but not specifically complete arterial obstruction. The coldness in the foot and ankle is a result of severely reduced blood flow, which impairs the delivery of oxygen and nutrients to the tissues in that area, leading to a lower temperature. This symptom is a critical indicator of a more severe blockage compared to the other options provided.

Similar Questions