medical surgical testbank
Exam 1
fluid and electrolyres
acid base
thermoregula on
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances
---
1. The nurse obtains all of the following assessment data about a pa ent 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 ten ng over the sternum.
The blood pressure is 90/40 mm Hg.
Ra onale: The blood pressure indicates that the pa ent may be developing hypovolemic shock as a
result of fluid loss. This will require immediate interven on to prevent the complica ons associated
with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin ten ng all
indicate the need for increasing the pa ents fluid intake but not as urgently as the hypotension.
2. A recently admi ed pa ent has a small cell carcinoma of the lung, which is causing the syndrome of
inappropriate an diure c hormone (SIADH). The nurse will monitor carefully for
a.
increased total urinary output.
,b.
eleva on of serum hematocrit.
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss.
decreased serum sodium level.
Ra onale: SIADH causes water reten on 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 reten on.
3. When the nurse is evalua ng the fluid balance for a pa ent admi ed for hypovolemia associated
with mul ple draining wounds, the most accurate assessment to include is
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output.
daily weight.
Ra onale: 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 fluid
moves into the inters al space and causes edema. Hourly urine outputs do not take account of fluid
intake or of fluid loss through insensible loss, swea ng, or loss from the gastrointes nal tract or
wounds.
,4. When caring for an alert and oriented elderly pa ent with a history of dehydra on, the home
health nurse will teach the pa ent to increase fluid intake
a.
in the late evening hours.
b.
if the oral mucosa feels dry.
c.
when the pa ent feels thirsty.
d.
as soon as changes in level of consciousness (LOC) occur.
if the oral mucosa feels dry.
Ra onale: An alert, elderly pa ent will be able to self-assess for signs of oral dryness such as thick oral
secre ons or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate
indicator of volume deple on. Many older pa ents prefer to restrict fluids slightly in the evening to
improve sleep quality. The pa ent will not be likely to no ce and act appropriately when changes in
LOC occur.
5. A pa ent is taking a potassium-was ng diure c for treatment of hypertension. The nurse will teach
the pa ent to report symptoms of adverse effects such as
a.
personality changes.
b.
frequent loose stools.
c.
facial muscle spasms.
d.
, generalized weakness.
generalized weakness.
Ra onale: Generalized weakness progressing to flaccidity is a manifesta on of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia.
Personality changes are not associated with electrolyte disturbances, although changes in mental
status are common manifesta ons with sodium excess or deficit.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a pa ent as a diure c.
Which statement by the pa ent indicates that the teaching about this medica on has been effec ve?
a.
I will try to drink at least 8 glasses of water every day.
b.
I will use a salt subs tute to decrease my sodium intake.
c.
I will increase my intake of potassium-containing foods.
d.
I will drink apple juice instead of orange juice for breakfast.
I will drink apple juice instead of orange juice for breakfast.
Ra onale: Since spironolactone is a potassium-sparing diure c, pa ents should be taught to choose
low potassium foods such as apple juice rather than foods that have higher levels of potassium, such
as citrus fruits. Because the pa ent is using spironolactone as a diure c, the nurse would not
encourage the pa ent to increase fluid intake. Teach pa ents to avoid salt subs tutes, which are high
in potassium.
7. When caring for a pa ent admi ed with hyponatremia, which ac ons will the nurse an cipate
taking?
a.
Restrict pa ents oral free water intake.
b.
Exam 1
fluid and electrolyres
acid base
thermoregula on
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances
---
1. The nurse obtains all of the following assessment data about a pa ent 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 ten ng over the sternum.
The blood pressure is 90/40 mm Hg.
Ra onale: The blood pressure indicates that the pa ent may be developing hypovolemic shock as a
result of fluid loss. This will require immediate interven on to prevent the complica ons associated
with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin ten ng all
indicate the need for increasing the pa ents fluid intake but not as urgently as the hypotension.
2. A recently admi ed pa ent has a small cell carcinoma of the lung, which is causing the syndrome of
inappropriate an diure c hormone (SIADH). The nurse will monitor carefully for
a.
increased total urinary output.
,b.
eleva on of serum hematocrit.
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss.
decreased serum sodium level.
Ra onale: SIADH causes water reten on 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 reten on.
3. When the nurse is evalua ng the fluid balance for a pa ent admi ed for hypovolemia associated
with mul ple draining wounds, the most accurate assessment to include is
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output.
daily weight.
Ra onale: 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 fluid
moves into the inters al space and causes edema. Hourly urine outputs do not take account of fluid
intake or of fluid loss through insensible loss, swea ng, or loss from the gastrointes nal tract or
wounds.
,4. When caring for an alert and oriented elderly pa ent with a history of dehydra on, the home
health nurse will teach the pa ent to increase fluid intake
a.
in the late evening hours.
b.
if the oral mucosa feels dry.
c.
when the pa ent feels thirsty.
d.
as soon as changes in level of consciousness (LOC) occur.
if the oral mucosa feels dry.
Ra onale: An alert, elderly pa ent will be able to self-assess for signs of oral dryness such as thick oral
secre ons or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate
indicator of volume deple on. Many older pa ents prefer to restrict fluids slightly in the evening to
improve sleep quality. The pa ent will not be likely to no ce and act appropriately when changes in
LOC occur.
5. A pa ent is taking a potassium-was ng diure c for treatment of hypertension. The nurse will teach
the pa ent to report symptoms of adverse effects such as
a.
personality changes.
b.
frequent loose stools.
c.
facial muscle spasms.
d.
, generalized weakness.
generalized weakness.
Ra onale: Generalized weakness progressing to flaccidity is a manifesta on of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia.
Personality changes are not associated with electrolyte disturbances, although changes in mental
status are common manifesta ons with sodium excess or deficit.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a pa ent as a diure c.
Which statement by the pa ent indicates that the teaching about this medica on has been effec ve?
a.
I will try to drink at least 8 glasses of water every day.
b.
I will use a salt subs tute to decrease my sodium intake.
c.
I will increase my intake of potassium-containing foods.
d.
I will drink apple juice instead of orange juice for breakfast.
I will drink apple juice instead of orange juice for breakfast.
Ra onale: Since spironolactone is a potassium-sparing diure c, pa ents should be taught to choose
low potassium foods such as apple juice rather than foods that have higher levels of potassium, such
as citrus fruits. Because the pa ent is using spironolactone as a diure c, the nurse would not
encourage the pa ent to increase fluid intake. Teach pa ents to avoid salt subs tutes, which are high
in potassium.
7. When caring for a pa ent admi ed with hyponatremia, which ac ons will the nurse an cipate
taking?
a.
Restrict pa ents oral free water intake.
b.
