Nursing Elites

1. An increase in capillary blood pressure would tend to:

• A. increase interstitial fluid volume.
• B. increase plasma volume.
• C. decrease interstitial fluid volume.
• D. increase plasma volume and decrease interstitial fluid volume.

Correct answer: A

Rationale: An increase in capillary blood pressure leads to a higher force pushing fluid out of the capillaries into the interstitial space, thereby increasing interstitial fluid volume. Choice B is incorrect because capillary blood pressure affects the movement of fluid into the interstitial space, not into the plasma. Choice C is incorrect as an increase in capillary blood pressure would not decrease interstitial fluid volume. Choice D is incorrect as it combines contradictory effects when capillary blood pressure increases.

2. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?

• A. I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup
• B. Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.
• C. It is normal to be a little confused following surgery, and it is safe not to urinate at night.
• D. If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.

Correct answer: B

Rationale:

3. Which condition can result from prolonged vomiting or diarrhea?

• A. Intracellular fluid
• B. Interstitial fluid
• C. Dehydration
• D. Electrolyte

Correct answer: C

Rationale: The correct answer is C: Dehydration. Prolonged vomiting or diarrhea can lead to significant fluid loss, causing dehydration. Intracellular fluid (choice A) and interstitial fluid (choice B) refer to specific compartments of body fluid and are not conditions resulting from vomiting or diarrhea. Electrolytes (choice D) are minerals that help maintain fluid balance in the body but are not the condition directly resulting from prolonged vomiting or diarrhea.

4. A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment, the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:

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

Correct answer: B

Rationale: The patient's symptoms of tingling in the lips and fingers along with the wrist and hand spasm are indicative of tetany, a characteristic manifestation of hypocalcemia. Hypocalcemia and hypomagnesemia can present with sensations of tingling in the extremities and around the mouth. The spasm in the wrist and hand when taking blood pressure could be due to slight ischemia of the ulnar nerve, further supporting the suspicion of hypocalcemia in this patient. Hypophosphatemia, hypermagnesemia, and hyperkalemia do not typically present with these specific symptoms and manifestations.

5. While assessing clients on a medical-surgical unit, which client is at risk for hypokalemia?

• A. Client with pancreatitis who has continuous nasogastric suctioning
• B. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
• C. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
• D. Client with uncontrolled diabetes and a serum pH level of 7.33

Correct answer: A

Rationale: Continuous nasogastric suctioning can lead to hypokalemia due to the loss of gastric contents rich in potassium. Therefore, a client with pancreatitis who has continuous nasogastric suctioning is at risk for hypokalemia. Option B is incorrect because ACE inhibitors may lead to hyperkalemia, not hypokalemia. Option C is incorrect as receiving packed red blood cells can lead to hyperkalemia due to the potassium content in the blood product. Option D is incorrect because a serum pH level of 7.33 indicates acidosis, which is not directly associated with hypokalemia.

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