MEDICAL SURGICAL TESTBANK
Exam 1 - Correct Answer - fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances - Correct Answer -
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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. - Correct Answer - The
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. - Correct Answer - decreased 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. - Correct Answer - daily 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. - Correct Answer -
if the oral mucosa feels dry.
Exam 1 - Correct Answer - fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances - Correct Answer -
---
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. - Correct Answer - The
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. - Correct Answer - decreased 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. - Correct Answer - daily 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. - Correct Answer -
if the oral mucosa feels dry.
