Nursing Elites

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. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)

• A. Urine output of 25 mL/hr
• B. Serum potassium level of 5.4 mEq/L
• C. Blood osmolality of 250 mOsm/L
• D.

Correct answer: A

Rationale:

3. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

• A. Redness at the catheter insertion site
• B. Report of headache and stiff neck
• C. Temperature of 100.1 F (37.8 C)
• D. Pain rating of 8 on a scale of 0 to 10

Correct answer: B

Rationale:

4. What electrolyte value should be monitored when a patient is receiving a loop diuretic?

• A. Calcium levels
• B. Phosphorus levels
• C. Potassium levels
• D. Magnesium levels

Correct answer: C

Rationale: When a patient is receiving a loop diuretic like furosemide (Lasix), potassium levels should be monitored closely. Loop diuretics act on the ascending loop of Henle to inhibit the reabsorption of sodium and water, leading to potassium loss. Monitoring potassium levels is crucial to prevent hypokalemia, which can result in serious complications such as cardiac arrhythmias. Calcium levels (Choice A), phosphorus levels (Choice B), and magnesium levels (Choice D) are not typically affected directly by loop diuretics and do not require routine monitoring in this context.

5. Which organ has the greatest effect on fluid output?

• A. Kidneys
• B. Lungs
• C. Skin
• D. Intestines

Correct answer: A

Rationale: The correct answer is the kidneys. The kidneys are primarily responsible for regulating fluid balance by filtering blood and adjusting the volume and concentration of urine. The lungs primarily regulate gas exchange, not fluid balance. The skin plays a role in temperature regulation and protection but is not the primary organ for fluid output. The intestines are mainly involved in the absorption of nutrients and water, rather than fluid output.

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