1. A nurse is assessing a patient in the ICU. The patient has the following signs: weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
A) Hypoglycemic patient B) Hyperglycemic patient C) Cardiac arrest D) End-stage renal failure
2. Medical records indicate a patient has developed a condition of respiratory alkalosis. Which of the following clinical signs would not apply to a condition of respiratory alkalosis?
A) Muscle tetany B) Syncope C) Numbness D) Anxiety
3. Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)
A) Greater than 1000 cells per deciliter B) Less than 500 cells per deciliter C) Greater than 2000 cells per deciliter D) Less than 200 cells per deciliter
4. A nurse is assessing a patient that has undergone a recent CABG. The nurse notices a mole with irregular edges with a bluish color. The nurse should:
A) Recommend a dermatological consult to the MD. B) Note the location of the mole and contact the physician via the telephone. C) Note the location of the mole and follow-up with the attending physician via the medical record and phone call. D) Remove the mole with a sharp - s debridement technique, following charge nurse approval.
5. A nurse is assessing a 18 year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician, due to the possibility the patient is experiencing which of the following conditions?
A) Increased intracranial pressure B) Increased function of cranial nerve X C) Sympathetic response to activity D) Meningitis
1. Right Answer: B Explanation: All of the clinical signs indicate a hyperglycemic condition.
2. Right Answer: D Explanation: Anxiety is a clinical sign associated with respiratory acidosis.
3. Right Answer: D Explanation: <200 T4 cells/deciliter
4. Right Answer: C Explanation: Contacting the attending physician via the medical record is appropriate due to the possibility of melanoma.
5. Right Answer: A Explanation: The patient is at high risk of developing increased intracranial pressure (ICP).
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