Nokea
The nurse assessing skin turgor in an elderly patient should remember that:
- A. Overhydration causes the skin to tent.
- B. Dehydration causes the skin to appear edematous and spongy.
- C. Inelastic skin turgor is a normal part of aging.
- D. Normal skin turgor is moist and boggy.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:
- A. Neuromuscular function
- B. Bowel sounds
- C. Respiratory rate
- D. Electrocardiogram (ECG) results
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse in the intensive care unit receives arterial blood gases (ABG) with a patient who is complaining of being 'short of breath.' The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mm Hg. The labs reflect:
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Metabolic acidosis
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is evaluating a patient's laboratory results. Based upon the laboratory findings, what results will cause the release of an antidiuretic hormone (ADH)?
- A. Increased serum sodium
- B. Decreased serum sodium
- C. Decrease in serum osmolality
- D. Decrease in thirst
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate?
- A. Hypermagnesemia
- B. Hypomagnesemia
- C. Hypocalcemia
- D. Hyperkalemia
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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.