Nursing Elites

1. The chief mechanism for maintaining fluid balance is to:

• A. adjust fluid intake so it equals fluid output.
• B. adjust fluid intake so it is slightly above fluid output.
• C. adjust fluid output so it equals fluid input.
• D. adjust fluid intake so it is slightly below fluid output.

Correct answer: C

Rationale: The correct answer is C: 'adjust fluid output so it equals fluid input.' Maintaining fluid balance involves ensuring that the amount of fluid lost through processes like urination, sweating, and respiration equals the amount of fluid taken in. This ensures that the body stays properly hydrated. Choices A, B, and D are incorrect because they do not focus on the balance between fluid input and output, which is crucial for maintaining proper fluid balance. By adjusting fluid output to equal fluid input, the body can regulate hydration levels effectively, preventing dehydration or overhydration.

2. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:

• A. Choose a proximal site.
• B. Choose a distal site.
• C. Have the patient hold their arm in a dependent position.
• D. Leave the tourniquet on for no longer than 2 minutes.

Correct answer: B

Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Opting for a distal site ensures that upper veins remain available for future cannulations. Instructing the patient to hold their arm in a dependent position can enhance blood flow, aiding in the procedure. It is crucial never to leave a tourniquet on for more than 2 minutes as prolonged restriction can lead to complications. Choice A is incorrect because a proximal site is not preferred for IV insertion. Choice C is incorrect as having the patient hold their arm over their head is not necessary and may impede proper blood flow. Choice D is incorrect as leaving the tourniquet on for at least 5 minutes is excessive and can be harmful.

3. While assessing a patient's peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

• A. Air emboli
• B. Phlebitis
• C. Infiltration
• D. Fluid overload

Correct answer: C

Rationale: Infiltration is the administration of a nonvesicant solution or medication into the surrounding tissue, typically due to the dislodgement or perforation of the vein wall by the IV cannula. It is characterized by edema around the insertion site, leakage of IV fluid, discomfort, coolness, and a decrease in flow rate. In this scenario, the presence of edema indicates infiltration, not air emboli, phlebitis, or fluid overload. Air emboli refer to air bubbles in the bloodstream, phlebitis is inflammation of the vein, and fluid overload is an excessive volume of fluid in the circulatory system.

4. The term used to describe a blood sodium level of more than 145 mEq/L is:

• A. hyponatremia.
• B. hyperkalemia.
• C. hypernatremia.
• D. hypercalcemia.

Correct answer: C

Rationale: The correct answer is C: hypernatremia. Hypernatremia refers to an elevated level of sodium in the blood, specifically when it is more than 145 mEq/L. Choice A, hyponatremia, is incorrect as it refers to low sodium levels. Choice B, hyperkalemia, is incorrect as it refers to high potassium levels, not sodium. Choice D, hypercalcemia, is also incorrect as it relates to elevated calcium levels, not sodium.

5. The healthcare provider is evaluating a patient's laboratory results. Based on the laboratory findings, what results will cause the release of an antidiuretic hormone (ADH)?

• A. Increased serum sodium
• B. Decreased serum sodium
• C. Decrease in serum osmolality
• D. Decrease in thirst

Correct answer: A

Rationale: The correct answer is A: Increased serum sodium. When serum sodium levels increase, it triggers the release of ADH by the posterior pituitary gland. ADH helps in retaining water, reducing urine output, and maintaining fluid balance. Choices B, C, and D are incorrect because decreased serum sodium, decrease in serum osmolality, and decrease in thirst do not stimulate the release of ADH.

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