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MCA Exam 1 With Questions And 100% ALL DETAILED CORRECT ANSWERS
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JACKLINEMCA Exam 1 With Questions And 100% ALL DETAILED CORRECT ANSWERS
Terms in this set (488)
Answer: 1
What is the nurse's primary concern regarding
fluid & electrolytes when caring for an elderly pt
Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered
who is intermittently confused?
level of consciousness, there is an increased risk of dehydration & high serum osmolality.
1. risk of dehydration
Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & electrolyte
2. risk of kidney damage
issues.
3. risk of stroke
Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues.
4. risk of bleeding
Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues.
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MCA Exam 1
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, Answer: 1
Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished, leading to
The nurse is planning care for a pt with severe an intracellular fluid deficit.
burns. Which of the following is this pt at risk for Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus.
developing? Because this pt was severely burned, the fluid within the cells is diminished, leading to an
1. intracellular fluid deficit intracellular fluid deficit.
2. intracellular fluid overload Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the interstitial
3. extracellular fluid deficit fluid between the cells. Because this pt was severely burned, the fluid within the cells is
4. interstitial fluid deficit diminished, leading to an intracellular fluid deficit.
Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the interstitial
fluid between the cells. Because this pt was severely burned, the fluid within the cells is
diminished, leading to an intracellular fluid deficit.
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A pt, experiencing multisystem fluid volume Answer: 1
deficit, has the symptoms of tachycardia, pale,
cool skin, & decreased urine output. The nurse Rationale 1: The internal vasoconstrictive compensatory reactions within the body are responsible
realizes these findings are most likely a direct for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically
result of which of the following? for the brain & heart.
1. the body's natural compensatory mechanisms Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
2. pharmacological effects of a diuretic Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output.
3. effects of rapidly infused intravenous fluids Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.
4. cardiac failure
Answer: 1
A pregnant pt is admitted with excessive thirst,
increased urination, & has a medical diagnosis of
Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabetes
diabetes insipidus. The nurse chooses which of the
insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can
following nursing diagnoses as most appropriate?
increase the serum levels of sodium.
1. Risk for Imbalanced Fluid Volume
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially during
2. Excess Fluid Volume
the early stages of treatment.
3. Imbalanced Nutrition
Rationale 3: Imbalanced Nutrition does not apply.
4. Ineffective Tissue Perfusion
Rationale 4: Ineffective Tissue Perfusion does not apply
MCA Exam 1
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, A pt recovering from surgery has an indwelling Answer: 1
urinary catheter. The nurse would contact the pt's Rationale 1: A urine output of less than 30 mL per hour must be reported to the primary
primary healthcare provider with which of the healthcare provider. This indicates inadequate renal perfusion, placing the pt at increased risk for
following 24-hour urine output volumes? acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over a 24-hour period is
1. 600 mL desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).
2. 750 mL
3. 1000 mL
4. 1200 mL
Answer: 1
A pt is receiving intravenous fluids postoperatively Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following the
following cardiac surgery. Nursing assessments stress response before, during, & immediately after surgery. This increase leads to sodium & water
should focus on which postoperative retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the
complication? heart & circulatory system.
1. fluid volume excess Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume
2. fluid volume deficit deficit, & stress upon the heart & circulatory system.
3. seizure activity Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances.
4. liver failure Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid
administration.
A pt is diagnosed with severe hyponatremia. The Answer: 1
nurse realizes this pt will mostly likely need which Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet
of the following precautions implemented? environment, raised side rails, & having an oral airway at the bedside would be included.
1. seizure Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia.
2. infection Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia.
3. neutropenic Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.
4. high-risk fall
A pt is diagnosed with hypokalemia. After Answer: 1
reviewing the pt's current medications, which of Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as
the following might have contributed to the pt's corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.
health problem? Rationale 2: Excessive sodium is lost with the use of thiazide diuretics.
1. corticosteroid Rationale 3: Narcotics do not typically affect electrolyte balance.
2. thiazide diuretic Rationale 4: Muscle relaxants do not typically affect electrolyte balance.
3. narcotic
4. muscle relaxer
MCA Exam 1
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