Nursing Elites

1. When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?

• A. Active transport of hydrogen ions across the capillary walls
• B. Pressure of the blood in the renal capillaries
• C. Action of the dissolved particles contained in a unit of blood
• D. Hydrostatic pressure resulting from the pumping action of the heart

Correct answer: D

Rationale:

2. After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?

• A. Toasted English muffin with butter and blueberry jam, and tea with sugar
• B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
• C. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
• D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

Correct answer: C

Rationale: Choice C is the correct answer as it includes foods high in potassium, such as raisins, whole wheat toast, and milk. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. Choices A, B, and D do not contain significant sources of potassium. Choice A consists mainly of carbohydrates and sugar, choice B focuses on protein and carbohydrates, and choice D provides carbohydrates and some fruit but lacks high-potassium options like in choice C.

3. A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously?

• A. Never, because it rapidly enters red blood cells, causing them to rupture.
• B. When the patient is severely dehydrated resulting in neurologic signs and symptoms
• C. When the patient is in excess of calcium and/or magnesium ions
• D. When a patients fluid volume deficit is due to acute or chronic renal failure

Correct answer: A

Rationale:

4. The nurse assessing skin turgor in an elderly patient should remember that:

• A. Overhydration causes the skin to tent.
• B. Dehydration causes the skin to appear edematous and spongy.
• C. Inelastic skin turgor is a normal part of aging.
• D. Normal skin turgor is moist and boggy.

Correct answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.

5. Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?

• A. Diminished deep tendon reflexes
• B. Tachycardia
• C. Cool clammy skin
• D. Increased serum magnesium

Correct answer: A

Rationale: The correct answer is A: Diminished deep tendon reflexes. In a patient with hypermagnesemia, the nurse would assess for diminished deep tendon reflexes. Hypermagnesemia can lead to neuromuscular depression, causing a decrease in deep tendon reflexes. Tachycardia (choice B) is more commonly associated with hypomagnesemia. Cool clammy skin (choice C) is not typically a direct symptom of hypermagnesemia. While hypermagnesemia does involve increased serum magnesium levels (choice D), assessing serum levels is a laboratory test and not a clinical assessment like checking deep tendon reflexes.

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