Nursing Elites

1. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

• A. Air emboli
• B. Phlebitis
• C. Infiltration
• D. Fluid overload

Correct answer: C

Rationale:

2. A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment, the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:

• A. Hypophosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hyperkalemia

Correct answer: B

Rationale: The patient's symptoms of tingling in the lips and fingers along with the wrist and hand spasm are indicative of tetany, a characteristic manifestation of hypocalcemia. Hypocalcemia and hypomagnesemia can present with sensations of tingling in the extremities and around the mouth. The spasm in the wrist and hand when taking blood pressure could be due to slight ischemia of the ulnar nerve, further supporting the suspicion of hypocalcemia in this patient. Hypophosphatemia, hypermagnesemia, and hyperkalemia do not typically present with these specific symptoms and manifestations.

3. You are working on a burns unit, and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

• A. Metabolic alkalosis
• B. Hypermagnesemia
• C. Hypercalcemia
• D. Hypovolemia

Correct answer: D

Rationale: Third spacing refers to the loss of fluid from the intravascular space into the interstitial or third space, leading to a decrease in circulating blood volume. This condition results in hypovolemia, which is characterized by decreased blood volume. Metabolic alkalosis, hypermagnesemia, and hypercalcemia are not directly associated with third spacing. Metabolic alkalosis is an acid-base imbalance, hypermagnesemia is an excess of magnesium in the blood, and hypercalcemia is an excess of calcium in the blood, none of which are the primary concerns in cases of third spacing.

4. . You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as

• A. Nutritional status
• B. Potassium balance
• C. Calcium balance
• D. Fluid volume status

Correct answer: D

Rationale:

5. What is the most important regulator of the amount of sodium in the body?

• A. Kidneys
• B. Small intestine
• C. Large intestine
• D. Skin

Correct answer: A

Rationale: The correct answer is A: Kidneys. The kidneys play a crucial role in regulating the amount of sodium in the body. They achieve this by filtering blood and controlling the excretion or reabsorption of sodium. The small intestine is primarily responsible for nutrient absorption, not sodium regulation. The large intestine is mainly involved in water absorption and waste elimination, not sodium balance. The skin helps regulate body temperature through sweating and does not directly regulate sodium levels.

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