10/8/23, 9:14 PM Lewis Medical Surgical chapter 16 text test bank 11th edition
Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances
Harding: Lewis’s Medical-Surgical Nursing, 11th Edition
MULTIPLE CHOICE
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for 8 hours.
d. Skin tenting over the sternum is prolonged.
ANS: B
The blood pressure indicates that the patient may be developing hypovolemic shock because
of intravascular fluid loss because of the burn injury. This finding will require immediate
intervention to prevent the complications associated with systemic hypoperfusion. The poor
oral intake, decreased urine output, and skin tenting all indicate the need for increasing the
patient’s fluid intake but not as urgently as the hypotension.
DIF: Cognitive Level: Analyze (analysis)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A patient who has a small cell cancer of the lung develops syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse should notify the health care provider about which
assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium of 120 mg/dL
c. Urinary output of 280 mL in 8 hours
d. Reported weight gain of 2.2 pounds (1 kg)
ANS: B
Hyponatremia is the most important finding to report. SIADH causes water retention and a
decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous
system effects. A critically low value needs to be treated. At least 30 mL/hr of urine output
indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected
with SIADH because of water retention.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. A patient with multiple draining wounds is admitted for hypovolemia. What would be the
most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor
b. Daily weight
c. Urine output
d. Edema presence
ANS: B
Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
NURSINGTB.COM
fluid moves into the interstitial space and causes edema. Urine outputs do not take account of
fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal
tract or wounds.
DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
4.
a “Drink more fluids in the late evening ”
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Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances
Harding: Lewis’s Medical-Surgical Nursing, 11th Edition
MULTIPLE CHOICE
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for 8 hours.
d. Skin tenting over the sternum is prolonged.
ANS: B
The blood pressure indicates that the patient may be developing hypovolemic shock because
of intravascular fluid loss because of the burn injury. This finding will require immediate
intervention to prevent the complications associated with systemic hypoperfusion. The poor
oral intake, decreased urine output, and skin tenting all indicate the need for increasing the
patient’s fluid intake but not as urgently as the hypotension.
DIF: Cognitive Level: Analyze (analysis)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A patient who has a small cell cancer of the lung develops syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse should notify the health care provider about which
assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium of 120 mg/dL
c. Urinary output of 280 mL in 8 hours
d. Reported weight gain of 2.2 pounds (1 kg)
ANS: B
Hyponatremia is the most important finding to report. SIADH causes water retention and a
decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous
system effects. A critically low value needs to be treated. At least 30 mL/hr of urine output
indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected
with SIADH because of water retention.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. A patient with multiple draining wounds is admitted for hypovolemia. What would be the
most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor
b. Daily weight
c. Urine output
d. Edema presence
ANS: B
Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
NURSINGTB.COM
fluid moves into the interstitial space and causes edema. Urine outputs do not take account of
fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal
tract or wounds.
DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
4.
a “Drink more fluids in the late evening ”
about:blank 1/14
