Nursing Clinical Skills questions

Nursing Clinical Skills questions Related

Review Nursing Clinical Skills questions related questions and content

A patient with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose: 648 mg/dL pH: 88 P CO : 20 mm Hg a 2 P O : 95 mm Hg a 2 HCO ¯: undetectable Anion gap: >31 Na+: 127 mEq/L K+: 5 mEq/L Creatinine: 8 mg/dL After the patient’s airway and ventilation have been established, the next priority for this patient is:

  • A. administration of a 1-L normal saline fluid bolus.
  • B. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion.
  • C. administration of 20 mEq KCl in 100 mL.
  • D. IV push administration of 1 amp of sodium bicarbonate.
Correct Answer: A

Rationale: The correct answer is A: administration of a 1-L normal saline fluid bolus. In this scenario, the patient is likely experiencing diabetic ketoacidosis (DKA) due to the extremely high glucose levels, low bicarbonate, and anion gap metabolic acidosis. The priority is to correct the dehydration and electrolyte imbalances through fluid resuscitation with normal saline to improve perfusion and reverse the metabolic derangements. Options B, C, and D do not address the immediate need for volume resuscitation and correction of dehydration. Administering insulin or potassium without first addressing the fluid deficit could lead to further complications. Sodium bicarbonate is not recommended in DKA as it can worsen acidosis and has not been shown to improve outcomes.

You may also like to solve these questions

The nurse is caring for a patient who suffered a head trauma following a fall. The patient’s heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 8 mg/dL. The findings are consistent with which disorder?

  • A. Cerebral salt wasting
  • B. Diabetes insipidus
  • C. Syndrome of inappropriate secretion of antidiuretic hormone
  • D. Thyroid storm
Correct Answer: A

Rationale: The correct answer is A: Cerebral salt wasting. This is indicated by the low serum sodium level (115 mEq/L), which can occur in patients with head trauma and lead to excessive sodium loss through the kidneys. This results in hypovolemia, leading to low blood pressure and tachycardia. The elevated BUN (50 mg/dL) and creatinine (8 mg/dL) levels suggest dehydration and renal impairment due to volume depletion. The patient's poor skin turgor, dry mucous membranes, confusion, and restlessness further support the diagnosis of cerebral salt wasting.

Summary:
B: Diabetes insipidus is characterized by excessive urination and thirst due to insufficient production of antidiuretic hormone (ADH). This patient's symptoms are not consistent with diabetes insipidus.
C: Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is characterized by excessive release of ADH, leading to water retention and

Daily weights are being recorded for the patient with a urine output that has been less than the intravenous and oral intake. The weight yesterday was 5 kg. This morning it is 99 kg. The nurse understands that this corresponds to a(n)

  • A. fluid retention of 1.5 liters.
  • B. fluid loss of 1.5 liters.
  • C. equal intake and output due to insensible losses.
  • D. fluid loss of 0.5 liters.
Correct Answer: A

Rationale: The correct answer is A: fluid retention of 1.5 liters. The weight gain from 5 kg to 99 kg indicates an increase of 94 kg. Since 1 kg of weight gain is approximately equal to 1 liter of fluid retention, the patient has retained 94 liters of fluid. Therefore, the correct choice is fluid retention of 1.5 liters.

Choice B is incorrect because the weight gain indicates fluid retention, not loss. Choice C is incorrect as it mentions equal intake and output, which does not match the weight gain observed. Choice D is incorrect as it suggests fluid loss, which contradicts the weight gain.

Which of the following would be seen in a patient with myxedema coma?

  • A. Decreased reflexes
  • B. Hyperthermia
  • C. Hyperventilation
  • D. Tachycardia
Correct Answer: A

Rationale: The correct answer is A: Decreased reflexes. In myxedema coma, a severe form of hypothyroidism, patients often present with decreased mental status, hypothermia, and bradycardia. Decreased reflexes are a common neurological manifestation due to the slowing of metabolic processes and the central nervous system depression associated with this condition. Hyperthermia (B) is not typically seen in myxedema coma, as patients usually have low body temperature. Hyperventilation (C) is also unlikely, as respiratory depression is more common. Tachycardia (D) is incorrect because bradycardia is more characteristic of myxedema coma.

A normal urine output is considered to be

  • A. 80 to 125 mL/min.
  • B. 180 L/day.
  • C. 80 mL/min.
  • D. 1 to 2 L/day.
Correct Answer: D

Rationale: The correct answer is D: 1 to 2 L/day. Normal urine output typically ranges from 1 to 2 liters per day, which is considered adequate for maintaining proper hydration and eliminating waste products. A: 80 to 125 mL/min is too low for daily output. B: 180 L/day is excessively high and unrealistic. C: 80 mL/min is also too low for daily urine output. Therefore, D is the most appropriate choice based on standard guidelines for urine excretion.

Which of the following laboratory values would be more common in patients with diabetic ketoacidosis?

  • A. Blood glucose >1000 mg/dL
  • B. Negative ketones in the urine
  • C. Normal anion gap
  • D. pH 7.24
Correct Answer: A

Rationale: The correct answer is A (Blood glucose >1000 mg/dL) because diabetic ketoacidosis is characterized by severe hyperglycemia. High blood glucose levels (>1000 mg/dL) are common due to insulin deficiency leading to increased glucose production.

B: Negative ketones in the urine would be incorrect as DKA results in ketone production, leading to ketonuria.

C: Normal anion gap would be incorrect as DKA typically presents with an elevated anion gap metabolic acidosis due to ketone accumulation.

D: pH 7.24 would be incorrect as DKA would present with a lower pH due to metabolic acidosis.

Copyright © 2025 Nokea. All rights reserved.