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1.1 EAQs Exam Questions And 100% Correct Answers Latest Update
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1.1 EAQs Exam Questions And 100% CorrectAnswers Latest Update
Which patient would have the largest percent of body water?
Premature infant.
(Least amount of fat tissue, thus largest water content).
A patient with HF inadvertently took an excess of the ordered diuretics. Which
respiratory symptom would the nurse expect to find?
Dyspnea
Pulmonary congestion
Increased rate
Moist crackles on inspiration
Increase Respiratory Rate
(Client with deficient fluid volume has impaired tissue perfusion and hypoxia, which
increases RR).
A family member asks the nurse to explain what "third spacing" means. She had heard
the nurse use this term when caring for their loved one with acute pancreatitis. Which of
the following explanations would most appropriately be given by the nurse?
A. "This is just a term that we use to describe generalized edema."
,B. "Third spacing refers to how the fluids are distributed in the cells and vessels."
C. "Third spacing refers to the potential sites where the fluid can be found, the cells,
blood vessels, and lymph system."
D. "The fluid becomes trapped between the cells or in the abdomen and cannot as easily
move back into the cells."
D. "The fluid becomes trapped between the cells or in the abdomen and cannot as easily
move back into the cells."
Third spacing refers to the "leaking" of fluid into nonfunctional spaces between cells.
Fluid becomes "trapped" there and cannot easily be returned to the cells. First spacing
refers to the normal distribution of fluids within the intracellular fluid and extracellular
fluid compartments. Second spacing is edema. "Extracellular" and "intracellular" refer
to locations that can host fluids within the cells, blood vessels, and lymph system.
Which of the following statements would the nurse use when explaining to a client why
his or her health care provider ordered a b-type natriuretic peptide (BNP)?
A. "The BNP is a diagnostic test to rule out retention of urine."
B. "The peptide is a blood test that is elevated in patients with hyponatremia."
C. "The blood test will tell us if there is excess fluid from the heart."
D. "The test is an x-ray to help diagnose stomach ulcers."
C. "The blood test will let us know if there is excess fluid in the heart."
(BNP is a hormone produced when the atrial pressure increases. This blood test is used
to diagnose the severity and results of the treatment of CHF. The atrial pressure
increases due to increased venous return and hypernatremia. The test gives no
information to rule out urine retention or the presence of stomach ulcers. A serum
sodium level is needed to determine hyponatremia.)
For which degree of edema would the nurse record if the patient's skin is cool, the
, sternal skin is taut, and pressure on the sternum with a thumb leaves a 2-mm
indentation?
A. 1+
B. 2+
C. 3+
D. 4+
A. 1+
Rationale:
Cool, taut, and hard skin indicates the accumulation of fluid. If, upon pressing with the
thumb to check for edema, it indents 2-mm, then it is grade 1+. If it indents 4-mm, it
merits a grade of 2+, if it indents 6-mm, it merits a grade of 3+, and an indentation of
8-mm merits a grade of 4+.
We have an expert-written solution to this problem!
Poor skin turgor manifests as skin that takes
20 to 30 seconds to return to normal after being pinched.
For which metabolic alteration would the nurse prepare to administer IV albumin in a 5%
solution?
A. Alkalosis.
B. Hypovolemia.
C. Hyperkalemia.
D. Mixed acid-base disorder.
B. Hypovolemia.
Albumin is a colloid solution that pulls fluid into the blood vessels, which restores blood
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