third spacing occurs when fluid moves out of the intravascular space but not into the intracellular space based upon this fluid shift the nurse will e

ATI RN

Fluid and Electrolytes ATI

1. 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.

2. Which hormones increase the amount of water in the body?

A. ADH
B. Aldosterone
C. ANH
D. ADH and aldosterone

Correct answer: D

Rationale: The correct answer is D, ADH and aldosterone. Both antidiuretic hormone (ADH) and aldosterone increase water retention by the kidneys, thereby increasing blood volume. ADH acts on the kidneys to increase water reabsorption, while aldosterone acts on the kidneys to promote sodium reabsorption, leading to water retention. Choice A, ADH, is partially correct as it alone increases water retention. Choice B, aldosterone, is also partially correct as it alone increases water retention. Choice C, ANH (atrial natriuretic hormone), actually decreases water retention by promoting sodium excretion and inhibiting aldosterone release.

3. You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?

A. Hypocalcemia
B. Hyponatremia
C. Hyperchloremia
D. Hypophosphatemia

Correct answer: C

Rationale:

4. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that do not apply.)

A. A 36-year-old who is malnourished
B. A 42-year-old with uncontrolled diabetes
C. A 76-year-old who is prescribed antacids
D. 50-year-old with hyperparathyroidism

Correct answer: C

Rationale:

5. Under normal circumstances, the kidneys provide the greatest means of water loss. Which organ provides the second greatest means of water loss?

A. Skin
B. Lungs
C. Intestines
D. Muscles

Correct answer: A

Rationale: The correct answer is A: Skin. After the kidneys, the skin is the second largest route of water loss through perspiration. Choice B, Lungs, is incorrect as the lungs primarily exchange gases and do not play a significant role in water loss. Choice C, Intestines, is also incorrect as water loss through the intestines is minimal since most water is reabsorbed during digestion. Choice D, Muscles, is incorrect as muscles are not a major source of water loss in the body.