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Medical Surgical
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,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 The blood pressure is 90/40 mm Hg.
about a patient with deficient fluid volume caused by a
massive burn injury. Which of the following assessment Rationale: The blood pressure indicates that the patient may be developing
data will be of greatest concern? hypovolemic shock as a result of fluid loss. This will require immediate
intervention to prevent the complications associated with systemic
a. 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
The blood pressure is 90/40 mm Hg. hypotension.
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.
2. A recently admitted patient has a small cell carcinoma decreased serum sodium level.
of the lung, which is causing the syndrome of
inappropriate antidiuretic hormone (SIADH). The nurse Rationale: SIADH causes water retention and a decrease in serum sodium level.
will monitor carefully for Weight loss, increased urine output, and elevated serum hematocrit may be
associated with excessive loss of water, but not with SIADH and water retention.
a.
increased total urinary output.
b.
elevation of serum hematocrit.
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss.
3. When the nurse is evaluating the fluid balance for a daily weight.
patient admitted for hypovolemia associated with multiple
draining wounds, the most accurate assessment to Rationale: Daily weight is the most easily obtained and accurate means of
include is assessing volume status. Skin turgor varies considerably with age. Considerable
excess fluid volume may be present before fluid moves into the interstitial space
a. 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
skin turgor. or wounds.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output.
,4. When caring for an alert and oriented elderly patient if the oral mucosa feels dry.
with a history of dehydration, the home health nurse will
teach the patient to increase fluid intake 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
a. 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
in the late evening hours. improve sleep quality. The patient will not be likely to notice and act appropriately
when changes in LOC occur.
b.
if the oral mucosa feels dry.
c.
when the patient feels thirsty.
d.
as soon as changes in level of consciousness (LOC)
occur.
5. A patient is taking a potassium-wasting diuretic for generalized weakness.
treatment of hypertension. The nurse will teach the
patient to report symptoms of adverse effects such as Rationale: Generalized weakness progressing to flaccidity is a manifestation of
hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose
a. stools are associated with hyperkalemia. Personality changes are not associated
with electrolyte disturbances, although changes in mental status are common
personality changes. manifestations with sodium excess or deficit.
b.
frequent loose stools.
c.
facial muscle spasms.
d.
generalized weakness.
6. Spironolactone (Aldactone), an aldosterone I will drink apple juice instead of orange juice for breakfast.
antagonist, is prescribed for a patient as a diuretic.
Which statement by the patient indicates that the Rationale: Since spironolactone is a potassium-sparing diuretic, patients should
teaching about this medication has been effective? be taught to choose low potassium foods such as apple juice rather than foods
that have higher levels of potassium, such as citrus fruits. Because the patient is
a. using spironolactone as a diuretic, the nurse would not encourage the patient to
increase fluid intake. Teach patients to avoid salt substitutes, which are high in
I will try to drink at least 8 glasses of water every day. potassium.
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.
, 7. When caring for a patient admitted with hyponatremia, Restrict patients oral free water intake.
which actions will the nurse anticipate taking?
Rationale: To help improve serum sodium levels, water intake is restricted.
a. Electrolyte-containing beverages will improve the patients sodium level.
Administration of vasopressin or hypotonic IV solutions will decrease the serum
Restrict patients oral free water intake. sodium level further.
b.
Avoid use of electrolyte-containing drinks.
c.
Infuse a solution of 5% dextrose in 0.45% saline.
d.
Administer vasopressin (antidiuretic hormone, [ADH]).
8. Intravenous potassium chloride (KCl) 60 mEq is Infuse the KCl at a rate of 20 mEq/hour.
prescribed for treatment of a patient with severe
hypokalemia. Which action should the nurse take? Rationale: Intravenous KCl is administered at a maximal rate of 20 mEq/hr.
Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred
a. concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L
may be used for some patients. KCl can cause inflammation of peripheral veins,
Administer the KCl as a rapid IV bolus. but it can be administered by this route.
b.
Infuse the KCl at a rate of 20 mEq/hour.
c.
Give the KCl only through a central venous line.
d.
Add no more than 40 mEq/L to a liter of IV fluid.
9. A postoperative patient who has been receiving Infuse 5% dextrose in water at 125 ml/hr.
nasogastric suction for 3 days has a serum sodium level
of 125 mEq/L (125 mmol/L). Which of these prescribed Rationale: Because the patients gastric suction has been depleting electrolytes,
therapies that the patient has been receiving should the the IV solution should include electrolyte replacement. Solutions such as lactated
nurse question? Ringers solution would usually be ordered for this patient. The other orders are
appropriate for a postoperative patient with gastric suction.
a.
Infuse 5% dextrose in water at 125 ml/hr.
b.
Administer IV morphine sulfate 4 mg every 2 hours PRN.
c.
Give IV metoclopramide (Reglan) 10 mg every 6 hours
PRN for nausea.
d.
Administer 3% saline if serum sodium drops to less than
128 mEq/L.
Medical Surgical
** Expert-Verified Explanation
** Questions with Verified Answer
** New Edition |Updated
** Guaranteed Pass
** 100% Correct Answers | Graded A+
,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 The blood pressure is 90/40 mm Hg.
about a patient with deficient fluid volume caused by a
massive burn injury. Which of the following assessment Rationale: The blood pressure indicates that the patient may be developing
data will be of greatest concern? hypovolemic shock as a result of fluid loss. This will require immediate
intervention to prevent the complications associated with systemic
a. 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
The blood pressure is 90/40 mm Hg. hypotension.
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.
2. A recently admitted patient has a small cell carcinoma decreased serum sodium level.
of the lung, which is causing the syndrome of
inappropriate antidiuretic hormone (SIADH). The nurse Rationale: SIADH causes water retention and a decrease in serum sodium level.
will monitor carefully for Weight loss, increased urine output, and elevated serum hematocrit may be
associated with excessive loss of water, but not with SIADH and water retention.
a.
increased total urinary output.
b.
elevation of serum hematocrit.
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss.
3. When the nurse is evaluating the fluid balance for a daily weight.
patient admitted for hypovolemia associated with multiple
draining wounds, the most accurate assessment to Rationale: Daily weight is the most easily obtained and accurate means of
include is assessing volume status. Skin turgor varies considerably with age. Considerable
excess fluid volume may be present before fluid moves into the interstitial space
a. 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
skin turgor. or wounds.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output.
,4. When caring for an alert and oriented elderly patient if the oral mucosa feels dry.
with a history of dehydration, the home health nurse will
teach the patient to increase fluid intake 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
a. 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
in the late evening hours. improve sleep quality. The patient will not be likely to notice and act appropriately
when changes in LOC occur.
b.
if the oral mucosa feels dry.
c.
when the patient feels thirsty.
d.
as soon as changes in level of consciousness (LOC)
occur.
5. A patient is taking a potassium-wasting diuretic for generalized weakness.
treatment of hypertension. The nurse will teach the
patient to report symptoms of adverse effects such as Rationale: Generalized weakness progressing to flaccidity is a manifestation of
hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose
a. stools are associated with hyperkalemia. Personality changes are not associated
with electrolyte disturbances, although changes in mental status are common
personality changes. manifestations with sodium excess or deficit.
b.
frequent loose stools.
c.
facial muscle spasms.
d.
generalized weakness.
6. Spironolactone (Aldactone), an aldosterone I will drink apple juice instead of orange juice for breakfast.
antagonist, is prescribed for a patient as a diuretic.
Which statement by the patient indicates that the Rationale: Since spironolactone is a potassium-sparing diuretic, patients should
teaching about this medication has been effective? be taught to choose low potassium foods such as apple juice rather than foods
that have higher levels of potassium, such as citrus fruits. Because the patient is
a. using spironolactone as a diuretic, the nurse would not encourage the patient to
increase fluid intake. Teach patients to avoid salt substitutes, which are high in
I will try to drink at least 8 glasses of water every day. potassium.
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.
, 7. When caring for a patient admitted with hyponatremia, Restrict patients oral free water intake.
which actions will the nurse anticipate taking?
Rationale: To help improve serum sodium levels, water intake is restricted.
a. Electrolyte-containing beverages will improve the patients sodium level.
Administration of vasopressin or hypotonic IV solutions will decrease the serum
Restrict patients oral free water intake. sodium level further.
b.
Avoid use of electrolyte-containing drinks.
c.
Infuse a solution of 5% dextrose in 0.45% saline.
d.
Administer vasopressin (antidiuretic hormone, [ADH]).
8. Intravenous potassium chloride (KCl) 60 mEq is Infuse the KCl at a rate of 20 mEq/hour.
prescribed for treatment of a patient with severe
hypokalemia. Which action should the nurse take? Rationale: Intravenous KCl is administered at a maximal rate of 20 mEq/hr.
Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred
a. concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L
may be used for some patients. KCl can cause inflammation of peripheral veins,
Administer the KCl as a rapid IV bolus. but it can be administered by this route.
b.
Infuse the KCl at a rate of 20 mEq/hour.
c.
Give the KCl only through a central venous line.
d.
Add no more than 40 mEq/L to a liter of IV fluid.
9. A postoperative patient who has been receiving Infuse 5% dextrose in water at 125 ml/hr.
nasogastric suction for 3 days has a serum sodium level
of 125 mEq/L (125 mmol/L). Which of these prescribed Rationale: Because the patients gastric suction has been depleting electrolytes,
therapies that the patient has been receiving should the the IV solution should include electrolyte replacement. Solutions such as lactated
nurse question? Ringers solution would usually be ordered for this patient. The other orders are
appropriate for a postoperative patient with gastric suction.
a.
Infuse 5% dextrose in water at 125 ml/hr.
b.
Administer IV morphine sulfate 4 mg every 2 hours PRN.
c.
Give IV metoclopramide (Reglan) 10 mg every 6 hours
PRN for nausea.
d.
Administer 3% saline if serum sodium drops to less than
128 mEq/L.
