Nursing Elites

1. What is the fluid that surrounds the cells called?

• A. plasma
• B. interstitial fluid
• C. intracellular fluid
• D. edema

Correct answer: B

Rationale: The correct answer is interstitial fluid. Interstitial fluid is the fluid that surrounds and fills the spaces between cells, facilitating nutrient and waste exchange. Plasma, referred to in choice A, is the liquid part of blood. Choice C, intracellular fluid, is the fluid inside cells. Choice D, edema, is an abnormal accumulation of fluid in interstitial spaces, causing swelling.

2. 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.

3. You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?

• A. Hypernatremia
• B. Hypomagnesemia
• C. Hypophosphatemia
• D. Hypercalcemia

Correct answer: D

Rationale:

4. You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?

• A. Hypocalcemia
• B. Hyponatremia
• C. Hyperchloremia
• D. Hypophosphatemia

Correct answer: C

Rationale:

5. A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

• A. The initial site dressing is 3 days old.
• B. The PICC was inserted 4 weeks ago.
• C. A securement device is absent.
• D. Upper extremity swelling is noted.

Correct answer: D

Rationale:

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