Nursing Elites

1. . A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?

• A. The catheter has been in place for 20 hours.
• B. . The client has poor vascular access in the upper extremities.
• C. The catheter is placed in the proximal tibia.
• D. The clients left lower extremity is cool to the touch.

Correct answer: D

Rationale:

2. Where is the largest volume of water in the body located?

• A. Plasma
• B. The fluid inside the cells
• C. Interstitial fluid
• D. Lymph

Correct answer: B

Rationale: The correct answer is B. The largest volume of water in the body is found inside the cells, known as intracellular fluid. This fluid makes up the majority of the body's total water content. Choices A, C, and D are incorrect because while plasma, interstitial fluid, and lymph are important components of the body's fluid compartments, they do not contain the largest volume of water in the body.

3. You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly?

• A. Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly.
• B. Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.
• C. Malnourished patients who receive fluids too rapidly are at risk for hypernatremia.
• D. Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate

Correct answer: B

Rationale:

4. What can cause dehydration?

• A. Prolonged vomiting.
• B. Prolonged diarrhea.
• C. Too little fluid intake.
• D. Prolonged vomiting, diarrhea, and too little fluid intake.

Correct answer: D

Rationale: Dehydration can result from significant fluid loss due to vomiting, diarrhea, or inadequate fluid intake. Prolonged vomiting and diarrhea lead to excessive fluid loss from the body, contributing to dehydration. Similarly, not consuming enough fluids can also result in dehydration. Choice A and B are too specific as they only mention one cause each, while choice C is also correct but does not encompass all the potential causes of dehydration as mentioned in choice D.

5. Third spacing occurs when fluid moves out of the intravascular space but not into the intracellular space. Based on this fluid shift, the nurse will expect the patient to demonstrate:

• A. Hypertension
• B. Bradycardia
• C. Hypervolemia
• D. Hypovolemia

Correct answer: D

Rationale: In the scenario of third-spacing fluid shift, where fluid moves out of the intravascular space but not into the intracellular space, the patient is expected to demonstrate hypovolemia. Hypertension (Choice A) is unlikely as hypovolemia typically leads to decreased blood pressure. Bradycardia (Choice B) is not a common manifestation of hypovolemia, as the body often tries to compensate by increasing heart rate. Hypervolemia (Choice C) indicates an excess of fluid, which is the opposite of what occurs in third spacing.

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