Nursing Elites

1. A 73-year-old man who slipped on a small carpet in his home and fell on his hip is alert and oriented; PERRLA (pupils equally round and reactive to light and accommodation) is intact, and he has come by ambulance to the emergency department (ED). Heart rate elevated, he is anxious and thirsty. A Foley catheter is in place and 40mL of urine is present. The nurse's most likely explanation for the urine output is:

• A. The man urinated prior to his arrival in the ED and will probably not need to have the Foley catheter kept in place.
• B. The man has a brain injury, lacks ADH, and needs vasopressin.
• C. The man is in heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output.
• D. He is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

Correct answer: D

Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely cause of the lower urine output. Choices A, B, and C are incorrect because there is no indication of urination prior to arrival, brain injury, lack of ADH, or heart failure present in the scenario provided. The symptoms and context described point more towards a physiological response related to the sympathetic nervous system and the renin-angiotensin-aldosterone system rather than the other conditions mentioned.

2. The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?

• A. Hypermagnesemia
• B. Hyponatremia
• C. Hypocalcemia
• D. Hyperkalemia

Correct answer: C

Rationale:

3. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?

• A. A 34-year-old on NPO status who is receiving intravenous D5W
• B. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
• C. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
• D. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

Correct answer: A

Rationale: The correct answer is the 34-year-old on NPO status receiving intravenous D5W because D5W is a hypotonic solution that can dilute the blood's sodium levels, leading to hyponatremia. Patients on NPO status rely solely on intravenous fluids for hydration, making them more susceptible to electrolyte imbalances. Choices B, C, and D are less likely to cause hyponatremia. Choice B, the 50-year-old with an infection on a sulfonamide antibiotic, is at risk for allergic reactions or renal issues. Choice C, the 67-year-old taking ibuprofen, is at risk for gastrointestinal bleeding or kidney problems. Choice D, the 73-year-old on digoxin with tachycardia, is more likely to experience digoxin toxicity, affecting the heart's rhythm.

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. What happens first in dehydration?

• A. Intercellular fluid volume drops first.
• B. Plasma volume drops first.
• C. Interstitial fluid drops first.
• D. Neither interstitial nor intracellular fluid volume are affected.

Correct answer: C

Rationale: In dehydration, the body first draws fluid from the interstitial space to maintain blood volume, leading to a decrease in interstitial fluid volume. This is why choice C is correct. Choice A is incorrect because intracellular fluid is not the first to be affected. Choice B is also incorrect as plasma volume reduction typically occurs after interstitial fluid loss. Choice D is incorrect as dehydration impacts both interstitial and intracellular fluid volumes.

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