Nursing Elites

1. The chief mechanism for maintaining fluid balance is to:

• A. adjust fluid intake so it equals fluid output.
• B. adjust fluid intake so it is slightly above fluid output.
• C. adjust fluid output so it equals fluid input.
• D. adjust fluid intake so it is slightly below fluid output.

Correct answer: C

Rationale: The correct answer is C: 'adjust fluid output so it equals fluid input.' Maintaining fluid balance involves ensuring that the amount of fluid lost through processes like urination, sweating, and respiration equals the amount of fluid taken in. This ensures that the body stays properly hydrated. Choices A, B, and D are incorrect because they do not focus on the balance between fluid input and output, which is crucial for maintaining proper fluid balance. By adjusting fluid output to equal fluid input, the body can regulate hydration levels effectively, preventing dehydration or overhydration.

2. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

• A. Monitor daily hemoglobin and hematocrit values.
• B. Administer furosemide (Lasix) intravenously.
• C. Encourage the client to take deep breaths.
• D. Teach the client fall prevention measures.

Correct answer: D

Rationale:

3. 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: In a patient with a serum potassium level of 6 mEq/L due to spironolactone use, the nurse's priority is to assess the Electrocardiogram (ECG) results. Hyperkalemia can lead to life-threatening arrhythmias, such as ventricular fibrillation, which can be detected on an ECG. While changes in neuromuscular function, bowel sounds, and respiratory rate can occur with hyperkalemia, the most critical assessment related to the patient's condition would be monitoring the ECG for signs of cardiac complications.

4. What is the most abundant positive ion in blood plasma?

• A. Potassium.
• B. Calcium.
• C. Sodium.
• D. Both potassium and sodium are in equal concentrations.

Correct answer: C

Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.

5. A patient with hypokalemia and heart failure is admitted to the telemetry unit. The nurse is aware that hypokalemia could cause which of the following abnormalities on an electrocardiogram (ECG)?

• A. Shortened P-R interval
• B. Inverted T wave
• C. Depressed U wave
• D. Elevated U wave

Correct answer: D

Rationale: The correct answer is D: Elevated U wave. Hypokalemia is associated with ECG changes such as an elevated U wave and flattened T waves. Choice A, a shortened P-R interval, is not typically seen in hypokalemia. Choice B, an inverted T wave, is more commonly associated with ischemia or CNS injury rather than hypokalemia. Choice C, a depressed U wave, is not a typical ECG abnormality seen in hypokalemia. Therefore, the correct ECG abnormality associated with hypokalemia is an elevated U wave.

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