Lewis: Medical-Surgical Nursing~Chapter 17 With Complete Solutions

Lewis: Medical-Surgical Nursing~Chapter 17 With Complete Solutions The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern? a. The blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum. - Answer Answer: a. The blood pressure is 90/40 mm Hg. The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This 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 patients fluid intake but not as urgently as the hypotension. A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for: a. increased total urinary output. b. elevation of serum hematocrit. c. decreased serum sodium level. d. rapid and unexpected weight loss. - Answer Answer: c. decreased serum sodium level. SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention. When the nurse is evaluating the fluid balance for a patient admitted for hypervolemia associated with multiple draining wounds, the most accurate assessment to include is: a. skin turgor. b. daily weight.