Full Test Bank for Medical-Surgical Nursing, 6th
Edition by Holly Stromberg
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. - 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. - 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. - 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. - 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 hypertension. The nurse will
teach the patient to report symptoms of adverse effects such as
Edition by Holly Stromberg
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. - 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. - 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. - 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. - 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 hypertension. The nurse will
teach the patient to report symptoms of adverse effects such as
