MED SURGE 4th EDITION EXAM WITH CORRECT ANSWERS
1. The nurse is caring for a client with deficient fluid volume caused by a massive burn injury.
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Which of the following assessment data will be of greatest concern to the nurse?
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a. The blood pressure is 90/40 mm Hg.
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b. Urine output is 30 mL over the last hour.
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c. Oral fluid intake is 100 mL for the last 8 hours.
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d. There is prolonged skin tenting over the sternum. - correct answer : A
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The blood pressure indicates that the client may be developing hypovolemic shock as a result
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of fluid loss. This will require immediate intervention to prevent the complications associated
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with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting
q q q q q q q q q q q q
all indicate the need for increasing the client's fluid intake but not as urgently as the
q q q q q q q q q q q q q q q
hypotension.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
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MSC:
Physiological Integrity q
q 2. The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the
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syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following
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assessments should the nurse carefully monitor? q q q q q
a. Increased total urinary output
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b. Elevation of serum hematocrit
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c. Decreased serum sodium level
q q q q
,d. Rapid and unexpected weight loss - correct answer : C
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SIADH causes water retention and hyponatremia—a decrease in serum sodium level. Weight
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loss, increased urine output, and elevated serum hematocrit may be associated with excessive
q q q q q q q q q q q q
loss of water, but not with SIADH and water retention.
q q q q q q q q q
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
q q q q q q q
MSC:
Physiological Integrity q
q 3. The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with
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multiple draining wounds. Which of the following assessments is the most accurate to
q q q q q q q q q q q q
evaluate volume status in this client? q q q q q
a. Skin turgor
q q
b. Daily weight
q q
c. Presence of edema
q q q
d. Hourly urine output - correct answer : B
q q q q q q q q
NURSINGTB.COM
Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank q q q q q q q q
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
q q q q q q q q q q q q q q
turgor varies considerably with age. Considerable excess fluid volume may be present before
q q q q q q q q q q q q
fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take
q q q q q q q q q q q q q q
account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the
q q q q q q q q q q q q q q q
gastrointestinal tract or wounds. q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
q q q q q q q
MSC:
Physiological Integrity q
q 4. The nurse is caring for an alert and oriented older-adult client with a history of dehydration.
q q q q q q q q q q q q q q q q
Which of the following information should the home health nurse teach the client as to when
q q q q q q q q q q q q q q q
,to increase fluid intake?
q q q
a. In the late evening hours
q q q q q
b. If the oral mucosa feels dry
q q q q q q
c. When the client feels thirsty
q q q q q
d. As soon as changes in level of consciousness (LOC) occur - correct answer : B
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An alert, elderly client will be able to self-assess for signs of oral dryness such as thick oral
q q q q q q q q q q q q q q q q q
secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
q q q q q q q q q q q q q
accurate indicator of volume depletion. Many older clients prefer to restrict fluids slightly in
q q q q q q q q q q q q q
the evening to improve sleep quality. The client will not be likely to notice and act
q q q q q q q q q q q q q q q
appropriately when changes in LOC occur. q q q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
q q q q q q q
MSC:
Health Promotion and Maintenance q q q
q 5. The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of
q q q q q q q q q q q q q q q q
hypertension. Which of the following assessment data would the nurse include in the teaching q q q q q q q q q q q q q
plan?
a. Personality changes
q q
b. Frequent loose stools
q q q
c. Facial muscle spasms
q q q
d. Lower extremity weakness - correct answer : D
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Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia. Facial
q q q q q q q q q q q
muscle spasms might occur with hypocalcemia. Loose stools are associated with
q q q q q q q q q q
hyperkalemia. Personality changes are not associated with electrolyte disturbances, although q q q q q q q q q
changes in mental status are common manifestations with sodium excess or deficit.
q q q q q q q q q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
q q q q q q q
MSC:
Physiological Integrity q
, q 6. The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client
q q q q q q q q q q q q q q q q
indicates that the teaching about this medication has been effective? q q q q q q q q q
a. "I will try to drink at least eight glasses of water every day."
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b. "I will use a salt substitute to decrease my sodium intake."
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c. "I will increase my intake of potassium-containing foods."
q q q q q q q q
d. "I will drink apple juice instead of orange juice for breakfast." - correct answer : D
q q q q q q q q q q q q q q q q
NURSINGTB.COM
Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank q q q q q q q q
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose low
q q q q q q q q q q q q
potassium foods such as apple juice rather than foods that have higher levels of potassium,
q q q q q q q q q q q q q q
such as citrus fruits. Because the client is using spironolactone as a diuretic, the nurse would
q q q q q q q q q q q q q q q
not encourage the client to increase fluid intake. Teach clients to avoid salt substitutes, which
q q q q q q q q q q q q q q
are high in potassium.
q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
q q q q q q q
MSC:
Physiological Integrity q
q 7. The nurse is caring for a client admitted with hyponatremia. Which of the following actions
q q q q q q q q q q q q q q q
should the nurse anticipate implementing? q q q q
a. Restrict client's oral free water intake.
q q q q q q
b. Avoid use of electrolyte-containing drinks.
q q q q q
c. Infuse a solution of 5% dextrose in 0.45% saline.
q q q q q q q q q
d. Administer vasopressin (antidiuretic hormone, [ADH]). - correct answer : A
q q q q q q q q q q
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
q q q q q q q q q q
beverages will improve the client's sodium level. Administration of vasopressin or hypotonic
q q q q q q q q q q q
IV solutions will decrease the serum sodium level further.
q q q q q q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
q q q q q q q
MSC:
1. The nurse is caring for a client with deficient fluid volume caused by a massive burn injury.
q q q q q q q q q q q q q q q q q
Which of the following assessment data will be of greatest concern to the nurse?
q q q q q q q q q q q q q
a. The blood pressure is 90/40 mm Hg.
q q q q q q q
b. Urine output is 30 mL over the last hour.
q q q q q q q q q
c. Oral fluid intake is 100 mL for the last 8 hours.
q q q q q q q q q q q
d. There is prolonged skin tenting over the sternum. - correct answer : A
q q q q q q q q q q q q q
The blood pressure indicates that the client may be developing hypovolemic shock as a result
q q q q q q q q q q q q q q
of fluid loss. This will require immediate intervention to prevent the complications associated
q q q q q q q q q q q q
with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting
q q q q q q q q q q q q
all indicate the need for increasing the client's fluid intake but not as urgently as the
q q q q q q q q q q q q q q q
hypotension.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
q q q q q q q
MSC:
Physiological Integrity q
q 2. The nurse is caring for a client recently admitted with small cell carcinoma of the lung and the
q q q q q q q q q q q q q q q q q q
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following
q q q q q q q q q
assessments should the nurse carefully monitor? q q q q q
a. Increased total urinary output
q q q q
b. Elevation of serum hematocrit
q q q q
c. Decreased serum sodium level
q q q q
,d. Rapid and unexpected weight loss - correct answer : C
q q q q q q q q q q
SIADH causes water retention and hyponatremia—a decrease in serum sodium level. Weight
q q q q q q q q q q q
loss, increased urine output, and elevated serum hematocrit may be associated with excessive
q q q q q q q q q q q q
loss of water, but not with SIADH and water retention.
q q q q q q q q q
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
q q q q q q q
MSC:
Physiological Integrity q
q 3. The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated with
q q q q q q q q q q q q q q q
multiple draining wounds. Which of the following assessments is the most accurate to
q q q q q q q q q q q q
evaluate volume status in this client? q q q q q
a. Skin turgor
q q
b. Daily weight
q q
c. Presence of edema
q q q
d. Hourly urine output - correct answer : B
q q q q q q q q
NURSINGTB.COM
Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank q q q q q q q q
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
q q q q q q q q q q q q q q
turgor varies considerably with age. Considerable excess fluid volume may be present before
q q q q q q q q q q q q
fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take
q q q q q q q q q q q q q q
account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the
q q q q q q q q q q q q q q q
gastrointestinal tract or wounds. q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
q q q q q q q
MSC:
Physiological Integrity q
q 4. The nurse is caring for an alert and oriented older-adult client with a history of dehydration.
q q q q q q q q q q q q q q q q
Which of the following information should the home health nurse teach the client as to when
q q q q q q q q q q q q q q q
,to increase fluid intake?
q q q
a. In the late evening hours
q q q q q
b. If the oral mucosa feels dry
q q q q q q
c. When the client feels thirsty
q q q q q
d. As soon as changes in level of consciousness (LOC) occur - correct answer : B
q q q q q q q q q q q q q q q
An alert, elderly client will be able to self-assess for signs of oral dryness such as thick oral
q q q q q q q q q q q q q q q q q
secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
q q q q q q q q q q q q q
accurate indicator of volume depletion. Many older clients prefer to restrict fluids slightly in
q q q q q q q q q q q q q
the evening to improve sleep quality. The client will not be likely to notice and act
q q q q q q q q q q q q q q q
appropriately when changes in LOC occur. q q q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
q q q q q q q
MSC:
Health Promotion and Maintenance q q q
q 5. The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of
q q q q q q q q q q q q q q q q
hypertension. Which of the following assessment data would the nurse include in the teaching q q q q q q q q q q q q q
plan?
a. Personality changes
q q
b. Frequent loose stools
q q q
c. Facial muscle spasms
q q q
d. Lower extremity weakness - correct answer : D
q q q q q q q q
Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia. Facial
q q q q q q q q q q q
muscle spasms might occur with hypocalcemia. Loose stools are associated with
q q q q q q q q q q
hyperkalemia. Personality changes are not associated with electrolyte disturbances, although q q q q q q q q q
changes in mental status are common manifestations with sodium excess or deficit.
q q q q q q q q q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
q q q q q q q
MSC:
Physiological Integrity q
, q 6. The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client
q q q q q q q q q q q q q q q q
indicates that the teaching about this medication has been effective? q q q q q q q q q
a. "I will try to drink at least eight glasses of water every day."
q q q q q q q q q q q q q
b. "I will use a salt substitute to decrease my sodium intake."
q q q q q q q q q q q
c. "I will increase my intake of potassium-containing foods."
q q q q q q q q
d. "I will drink apple juice instead of orange juice for breakfast." - correct answer : D
q q q q q q q q q q q q q q q q
NURSINGTB.COM
Medical-Surgical Nursing in Canada 4th Edition Lewi Test Bank q q q q q q q q
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose low
q q q q q q q q q q q q
potassium foods such as apple juice rather than foods that have higher levels of potassium,
q q q q q q q q q q q q q q
such as citrus fruits. Because the client is using spironolactone as a diuretic, the nurse would
q q q q q q q q q q q q q q q
not encourage the client to increase fluid intake. Teach clients to avoid salt substitutes, which
q q q q q q q q q q q q q q
are high in potassium.
q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
q q q q q q q
MSC:
Physiological Integrity q
q 7. The nurse is caring for a client admitted with hyponatremia. Which of the following actions
q q q q q q q q q q q q q q q
should the nurse anticipate implementing? q q q q
a. Restrict client's oral free water intake.
q q q q q q
b. Avoid use of electrolyte-containing drinks.
q q q q q
c. Infuse a solution of 5% dextrose in 0.45% saline.
q q q q q q q q q
d. Administer vasopressin (antidiuretic hormone, [ADH]). - correct answer : A
q q q q q q q q q q
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
q q q q q q q q q q
beverages will improve the client's sodium level. Administration of vasopressin or hypotonic
q q q q q q q q q q q
IV solutions will decrease the serum sodium level further.
q q q q q q q q
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
q q q q q q q
MSC:
