Nokea
Which substance dissociates into ions in a water solution?
- A. Intracellular fluid
- B. Interstitial fluid
- C. Plasma
- D. Electrolyte
Correct Answer: D
Rationale: The correct answer is 'Electrolyte.' Electrolytes are substances that dissociate into ions when dissolved in water. Intracellular fluid, interstitial fluid, and plasma are not substances that dissociate into ions in a water solution. Intracellular fluid is the fluid inside cells, interstitial fluid is the fluid between cells, and plasma is the liquid component of blood. These choices do not dissociate into ions in a water solution, unlike electrolytes.
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A nurse is caring for a patient who requires measurement of specific gravity every 4 hours. What does this test detect?
- A. Nutritional deficit
- B. Hyperkalemia
- C. Hypercalcemia
- D. Fluid volume status
Correct Answer: D
Rationale: Specific gravity is a test used to determine the concentration of solutes in the urine, reflecting the kidney's ability to concentrate urine. Changes in specific gravity can indicate fluid volume status, such as dehydration (fluid volume deficit) or overhydration (fluid volume excess). Options A, B, and C are incorrect as specific gravity does not directly detect nutritional deficits, hyperkalemia, or hypercalcemia.
Which hormone reduces the amount of water in the body?
- A. ADH
- B. aldosterone
- C. ANH
- D. ADH and aldosterone
Correct Answer: B
Rationale: The correct answer is 'aldosterone.' Aldosterone is the hormone that reduces the amount of water in the body by increasing the reabsorption of sodium and water from the kidney tubules. ANH (atrial natriuretic hormone) actually works to increase the excretion of sodium and water by the kidneys, leading to a reduction in blood volume and pressure. ADH (antidiuretic hormone) works to increase water reabsorption by the kidneys, thereby increasing blood volume. Therefore, choices A (ADH) and D (ADH and aldosterone) are incorrect in the context of reducing the amount of water in the body.
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.
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.
When considering overhydration:
- A. occurs less often than dehydration.
- B. can strain the kidneys.
- C. can be caused by giving intravenous fluids too rapidly.
- D. less common than dehydration.
Correct Answer: C
Rationale: The correct answer is C. Overhydration can occur when intravenous fluids are administered too quickly, overwhelming the body's ability to excrete the excess fluid. Choices A, B, and D are incorrect. Choice A is incorrect because overhydration is less common than dehydration. Choice B is incorrect because while overhydration can strain the kidneys, it is not due to the burden being too heavy. Choice D is incorrect because dehydration is more common than overhydration.