Exam 1: Chapter 16- Test Bank
1. 1. The nurse is caring for a patient with a massive burn injury and
possible hypovolemia. Which assessment data will be of most concern to
the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum.: b. Blood pressure is 90/40
mm Hg.
2. 2. A patient who has a small cell carcinoma 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 level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours: b. Serum sodium level of 120
mg/dL
3. 3. A patient with multiple draining wounds is admitted for hypovolemia.
Which assessment would be the most accurate way for the nurse to
evaluate fluid balance?
a. Skin turgor c. Urine output
b. Daily weight d. Edema presence: b. Daily weight
4. 4. The home health nurse cares for an alert and oriented older adult patient
with a history of dehydration. Which instructions should the nurse give this
patient related to fluid intake?
a. "Drink more fluids in the late evening."
b. "Increase fluids if your mouth feels dry."
c. "More fluids are needed if you feel thirsty."
, Exam 1: Chapter 16- Test Bank
d. "If you feel confused, you need more to drink.": b. "Increase fluids if your
mouth feels dry."
5. 5. A patient who is taking a potassium-wasting diuretic for treatment of
hypertension complains of generalized weakness. Which action is
appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.: d.
Suggest that the health care provider order a basic metabolic panel.
6. 6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for
a patient. 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.": d. "I will drink
apple juice instead of orange juice for breakfast."
7. 7. A patient with new-onset confusion and hyponatremia is being admitted.
When making room assignments, the charge nurse should take which action?
a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurse's station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves..: b. Assign the
patient to a room near the nurse's station.
8. 8. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a
patient with severe hypokalemia. Which action should the nurse take?
1. 1. The nurse is caring for a patient with a massive burn injury and
possible hypovolemia. Which assessment data will be of most concern to
the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum.: b. Blood pressure is 90/40
mm Hg.
2. 2. A patient who has a small cell carcinoma 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 level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours: b. Serum sodium level of 120
mg/dL
3. 3. A patient with multiple draining wounds is admitted for hypovolemia.
Which assessment would be the most accurate way for the nurse to
evaluate fluid balance?
a. Skin turgor c. Urine output
b. Daily weight d. Edema presence: b. Daily weight
4. 4. The home health nurse cares for an alert and oriented older adult patient
with a history of dehydration. Which instructions should the nurse give this
patient related to fluid intake?
a. "Drink more fluids in the late evening."
b. "Increase fluids if your mouth feels dry."
c. "More fluids are needed if you feel thirsty."
, Exam 1: Chapter 16- Test Bank
d. "If you feel confused, you need more to drink.": b. "Increase fluids if your
mouth feels dry."
5. 5. A patient who is taking a potassium-wasting diuretic for treatment of
hypertension complains of generalized weakness. Which action is
appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.: d.
Suggest that the health care provider order a basic metabolic panel.
6. 6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for
a patient. 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.": d. "I will drink
apple juice instead of orange juice for breakfast."
7. 7. A patient with new-onset confusion and hyponatremia is being admitted.
When making room assignments, the charge nurse should take which action?
a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurse's station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves..: b. Assign the
patient to a room near the nurse's station.
8. 8. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a
patient with severe hypokalemia. Which action should the nurse take?
