Nursing Elites

1. Which of the following are sources of water intake?

• A. Drinking fluids.
• B. Consuming water from the food we eat.
• C. Water from metabolic processes.
• D. Drinking fluids, consuming water from the food we eat, and water from metabolic processes.

Correct answer: D

Rationale: The correct answer is D. The sources of water intake include drinking fluids, consuming water from the food we eat, and water from metabolic processes. Water intake is not solely from the liquids we drink but also from the water content present in the food we consume and the water produced during metabolic processes such as cellular respiration. Therefore, option D is the correct answer as it covers all the sources of water intake. Options A, B, and C alone do not encompass all the sources of water intake, making them incorrect choices.

2. During a visit to an 84-year-old woman recovering from hip surgery, the nurse notices signs of confusion and poor skin turgor. The woman mentions she limits water intake to avoid nighttime bathroom trips. The nurse should explain to the woman that:

• A. She will need her medications adjusted and be readmitted for a complete workup.
• B. Limiting fluids can lead to body imbalances causing confusion; perhaps adjusting fluid intake timing is necessary.
• C. Post-surgical confusion is common, and it's safe not to urinate at night.
• D. Confusion after surgery is typical in the elderly due to sleep loss.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid and electrolyte imbalances can manifest with subtle signs like confusion. Limiting fluids can lead to such imbalances, affecting cognitive function. Adjusting the timing of fluid intake can help maintain hydration without causing nighttime disruptions. Choices A, C, and D are incorrect. Choice A suggests unnecessary hospital readmission and medication adjustments without addressing the root cause. Choice C wrongly normalizes the confusion and fails to address the potential issue of fluid restriction. Choice D incorrectly attributes confusion solely to sleep loss without considering the impact of fluid balance.

3. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems?

• A. Diminished deep tendon reflexes
• B. Tachycardia
• C. Cool, clammy skin
• D. Acute flank pain

Correct answer: A

Rationale: Corrected Rationale: To assess a patient's magnesium status, the nurse should check deep tendon reflexes. Diminished deep tendon reflexes may indicate high serum magnesium levels, as hypermagnesemia can lead to neuromuscular effects. Tachycardia, cool clammy skin, and acute flank pain are not typically associated with high magnesium levels and are not priority assessments in this situation.

4. 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.

5. 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.

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