Medical-Surgical Nursing Test Bank | Fluid, Electrolyte, and Acid-Base Balance Questions with Rationales

medical surgical
testbank

,Exam 1 fluid and electrolyres
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acid base kr




thermoregulation

Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances
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1. The nurse obtains all of the following assessment data about a patient with deficient fluid volume
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caused by a massive burn injury. Which of the following assessment data will be of greatest concer
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n?



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.
kr kr kr kr kr kr kr The blood pressure is 90/40 mm Hg.
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Rationale: The blood pressure indicates that the patient may be developing hypovolemic shock as a
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result of fluid loss. This will require immediate intervention to prevent the complications associate
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,d with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all in
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dicate the need for increasing the patients fluid intake but not as urgently as the hypotension.
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2. A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome
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of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for
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a.



increased total urinary output. kr kr kr




b.



elevation of serum hematocrit. kr kr kr




c.



decreased serum sodium level. kr kr kr




d.



rapid and unexpected weight loss.
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Rationale: SIADH causes water retention and a decrease in serum sodium level. Weight loss, increa
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sed urine output, and elevated serum hematocrit may be associated with excessive loss of water, b
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ut not with SIADH and water retention.
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3. When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated
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with multiple draining wounds, the most accurate assessment to include is
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, a.



skin turgor. kr




b.



daily weight. kr




c.



presence of edema. kr kr




d.



hourly urine output. daily weight. kr kr kr




Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status.
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Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fl
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uid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of
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fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract o
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r wounds.
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4. When caring for an alert and oriented elderly patient with a history of dehydration, the home hea
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lth nurse will teach the patient to increase fluid intake
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a.



in the late evening hours.
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