Nursing Elites

1. Which of the following is not considered an extracellular fluid?

• A. Cerebrospinal fluid
• B. The humors of the eye
• C. Lymph
• D. Cerebrospinal fluid and the humors of the eye

Correct answer: D

Rationale: The correct answer is D. Cerebrospinal fluid and the humors of the eye are not considered extracellular fluids. Extracellular fluids are fluids found outside the cells, such as interstitial fluid and lymph. Cerebrospinal fluid is found within the central nervous system, while the humors of the eye (aqueous humor and vitreous humor) are located within the eyeball, making them distinct from extracellular fluids.

2. A patient admitted with a gastrointestinal bleed and anemia is receiving a blood transfusion. Based on the patient's hypotensive blood pressure, the nurse anticipates an order for IV fluids from the physician. Which of the following IV solutions may be administered with blood products?

• A. D5 and 0.45% Normal Saline
• B. Lactated Ringer's
• C. 5% dextrose in water
• D. 0.9% NaCl

Correct answer: D

Rationale: The correct answer is D: 0.9% NaCl. The only IV solution that can be administered with blood products is normal saline (0.9% NaCl). This solution is compatible with most blood products and is commonly used during transfusions to maintain hemodynamic stability. Choices A, B, and C are incorrect. Choice A, D5 and 0.45% Normal Saline, contains dextrose and is not recommended to be given simultaneously with blood products. Choice B, Lactated Ringer's, contains calcium, which can cause coagulation and should not be mixed with blood. Choice C, 5% dextrose in water, is hypotonic and not suitable to be administered with blood products.

3. You are working on a burns unit, and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

• A. Metabolic alkalosis
• B. Hypermagnesemia
• C. Hypercalcemia
• D. Hypovolemia

Correct answer: D

Rationale: When a patient exhibits signs and symptoms of third-spacing, where fluid moves out of the intravascular space but not into the intracellular space, hypovolemia is expected. This leads to a decreased circulating blood volume. Increased calcium and magnesium levels are not typically associated with third-spacing fluid shift. Burns usually result in acidosis rather than alkalosis, making metabolic alkalosis an incorrect choice. Therefore, hypovolemia is the correct answer in this scenario.

4. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

• A. Choose a site with minimal hair if available.
• B. Consider potential effects on the patient's mobility when selecting a site.
• C. Instruct the patient to hold his arm in a dependent position before insertion.
• D. Remove the tourniquet after 2 minutes.

Correct answer: B

Rationale: When selecting a site for IV insertion on the hand or arm, it is important to consider the potential effects on the patient's mobility. The chosen site should not interfere with the patient's movement. Instructing the patient to hold his arm in a dependent position helps increase blood flow, aiding in vein visualization and insertion. It is advisable to choose a site with minimal hair if possible for better adhesion of the dressing. Removing the tourniquet after 2 minutes is recommended to prevent complications like hemoconcentration and potential vein damage. Therefore, option B is the correct choice as it aligns with best practices for IV insertion.

5. A nurse is caring for a patient who requires measurement of specific gravity every 4 hours. What does this test detect?

• A. Nutritional deficit
• B. Hyperkalemia
• C. Hypercalcemia
• D. Fluid volume status

Correct answer: D

Rationale: Specific gravity is a test used to determine the concentration of solutes in the urine, reflecting the kidney's ability to concentrate urine. Changes in specific gravity can indicate fluid volume status, such as dehydration (fluid volume deficit) or overhydration (fluid volume excess). Options A, B, and C are incorrect as specific gravity does not directly detect nutritional deficits, hyperkalemia, or hypercalcemia.

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