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. Electrolytes:

• A. do not form when glucose is added to water.
• B. dissociate in water solutions, but do not form ions.
• C. form ions in water solutions, but do not necessarily dissociate.
• D. dissociate in water solutions and form ions in water solutions.

Correct answer: D

Rationale: The correct answer is D. Electrolytes are substances that dissociate into ions when dissolved in water, allowing the solution to conduct electricity. Choice A is incorrect because glucose does not form electrolytes when added to water. Choice B is incorrect as it states that electrolytes dissociate but do not form ions, which is inaccurate as electrolytes do form ions in water solutions. Choice C is also incorrect as it states that electrolytes form ions but may not necessarily dissociate, which goes against the definition of electrolytes that must dissociate into ions for conductivity. Therefore, choice D is the most accurate as it correctly describes that electrolytes dissociate in water solutions and form ions, highlighting the essential characteristics of electrolytes.

3. .A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?

• A. Apply cold compresses to the IV site.
• B. Elevate the extremity on a pillow.
• C. Flush the catheter with normal saline.
• D. . Stop the infusion of intravenous fluids.

Correct answer: D

Rationale:

4. 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.

5. The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:

• A. Daily weight
• B. Serum sodium levels
• C. Measured intake and output
• D. Blood pressure

Correct answer: A

Rationale: Daily weight is the most sensitive indicator of body fluid balance because it can show trends over time, helping in assessing the effectiveness of interventions and medications. While serum sodium levels provide objective data on electrolyte balance, they may not accurately reflect fluid balance, especially if a patient is dehydrated. Measured intake and output are crucial for assessing fluid balance, but it can be challenging to match the two due to various ways fluid is lost from the body. Blood pressure and other vital signs may not always be reliable indicators of fluid balance as they can be influenced by other factors beyond fluid status.

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