Nursing Elites

1. Where is the largest volume of water in the body located?

• A. Plasma
• B. The fluid inside the cells
• C. Interstitial fluid
• D. Lymph

Correct answer: B

Rationale: The correct answer is B. The largest volume of water in the body is found inside the cells, known as intracellular fluid. This fluid makes up the majority of the body's total water content. Choices A, C, and D are incorrect because while plasma, interstitial fluid, and lymph are important components of the body's fluid compartments, they do not contain the largest volume of water in the body.

2. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand, and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

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

Correct answer: B

Rationale: The symptoms described, including tingling in the lips and fingers, intermittent spasms, and increased muscle tone, are indicative of tetany, which is a common manifestation of hypocalcemia. Hypocalcemia can lead to neuromuscular irritability, causing symptoms such as paresthesias and muscle spasms. Hypophosphatemia primarily affects the central nervous system, resulting in seizures and coma. Hypermagnesemia typically presents with hypoactive reflexes and somnolence. Hyperkalemia can cause paresthesias and anxiety, but in this case, the patient's symptoms are more suggestive of hypocalcemia.

3. You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?

• A. Extravasation of the medication
• B. Discomfort to the patient
• C. Blanching at the site
• D. Hypersensitivity reaction to the medication

Correct answer: A

Rationale:

4. A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)

• A. Increased pulse rate
• B. . Distended neck veins
• C. Warm and pink skin
• D. Skeletal muscle weakness

Correct answer: C

Rationale:

5. Third spacing occurs when fluid moves out of the intravascular space but not into the intracellular space. Based on this fluid shift, the nurse will expect the patient to demonstrate:

• A. Hypertension
• B. Bradycardia
• C. Hypervolemia
• D. Hypovolemia

Correct answer: D

Rationale: In the scenario of third-spacing fluid shift, where fluid moves out of the intravascular space but not into the intracellular space, the patient is expected to demonstrate hypovolemia. Hypertension (Choice A) is unlikely as hypovolemia typically leads to decreased blood pressure. Bradycardia (Choice B) is not a common manifestation of hypovolemia, as the body often tries to compensate by increasing heart rate. Hypervolemia (Choice C) indicates an excess of fluid, which is the opposite of what occurs in third spacing.

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