medical surgical testbank
Exam 1 - ansfluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances - ans---
1. 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. - ansThe blood pressure is 90/40 mm
Hg.
Rationale: 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.
2. 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. - ansdecreased serum sodium level.
Rationale: 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.
3. When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia
associated with multiple draining wounds, the most accurate assessment to include is
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output. - ansdaily weight.
,Rationale: 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 interstitial space and causes edema.
Hourly 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.
4. When caring for an alert and oriented elderly patient with a history of dehydration, the
home health nurse will teach the patient to increase fluid intake
a.
in the late evening hours.
b.
if the oral mucosa feels dry.
c.
when the patient feels thirsty.
d.
as soon as changes in level of consciousness (LOC) occur. - ansif the oral mucosa feels
dry.
Rationale: An alert, elderly patient will be able to self-assess for signs of oral dryness
such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases
with age and is not an accurate indicator of volume depletion. Many older patients
prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will
not be likely to notice and act appropriately when changes in LOC occur.
5. A patient is taking a potassium-wasting diuretic for treatment of hypertension. The
nurse will teach the patient to report symptoms of adverse effects such as
a.
personality changes.
b.
, frequent loose stools.
c.
facial muscle spasms.
d.
generalized weakness. - ansgeneralized weakness.
Rationale: Generalized weakness progressing to flaccidity is a manifestation 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 manifestations with
sodium excess or deficit.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as
a diuretic. Which statement by the patient indicates that the teaching about this
medication has been effective?
a.
I will try to drink at least 8 glasses of water every day.
b.
I will use a salt substitute 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. - ansI will drink apple juice
instead of orange juice for breakfast.
Rationale: Since spironolactone is a potassium-sparing diuretic, patients should be
taught to choose low potassium foods such as apple juice rather than foods that have
Exam 1 - ansfluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances - ans---
1. 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. - ansThe blood pressure is 90/40 mm
Hg.
Rationale: 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.
2. 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. - ansdecreased serum sodium level.
Rationale: 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.
3. When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia
associated with multiple draining wounds, the most accurate assessment to include is
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output. - ansdaily weight.
,Rationale: 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 interstitial space and causes edema.
Hourly 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.
4. When caring for an alert and oriented elderly patient with a history of dehydration, the
home health nurse will teach the patient to increase fluid intake
a.
in the late evening hours.
b.
if the oral mucosa feels dry.
c.
when the patient feels thirsty.
d.
as soon as changes in level of consciousness (LOC) occur. - ansif the oral mucosa feels
dry.
Rationale: An alert, elderly patient will be able to self-assess for signs of oral dryness
such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases
with age and is not an accurate indicator of volume depletion. Many older patients
prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will
not be likely to notice and act appropriately when changes in LOC occur.
5. A patient is taking a potassium-wasting diuretic for treatment of hypertension. The
nurse will teach the patient to report symptoms of adverse effects such as
a.
personality changes.
b.
, frequent loose stools.
c.
facial muscle spasms.
d.
generalized weakness. - ansgeneralized weakness.
Rationale: Generalized weakness progressing to flaccidity is a manifestation 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 manifestations with
sodium excess or deficit.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as
a diuretic. Which statement by the patient indicates that the teaching about this
medication has been effective?
a.
I will try to drink at least 8 glasses of water every day.
b.
I will use a salt substitute 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. - ansI will drink apple juice
instead of orange juice for breakfast.
Rationale: Since spironolactone is a potassium-sparing diuretic, patients should be
taught to choose low potassium foods such as apple juice rather than foods that have
