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solution, latest update,A+ graded
Exam 1: fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances: ---
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.:(ans) 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.: (ans) 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.: (ans) 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.: (ans) if 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 hyperten-
sion. The nurse will teach the patient to report symptoms of adverse effects
such as
solution, latest update,A+ graded
Exam 1: fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances: ---
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.:(ans) 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.: (ans) 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.: (ans) 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.: (ans) if 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 hyperten-
sion. The nurse will teach the patient to report symptoms of adverse effects
such as
