Lewis Medical Surgical chapter 16 text test bank 11th edition

Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances Harding: Lewis’s Medical-Surgical Nursing, 11th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse? a. Urine output is 30 mL/hr. b. Blood pressure is 90/40 mm Hg. c. Oral fluid intake is 100 mL for 8 hours. d. Skin tenting over the sternum is prolonged. ANS: B The blood pressure indicates that the patient may be developing hypovolemic shock because of intravascular fluid loss because of the burn injury. This finding 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 patient’s fluid intake but not as urgently as the hypotension. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium of 120 mg/dL c. Urinary output of 280 mL in 8 hours d. Reported weight gain of 2.2 pounds (1 kg) ANS: B Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Urine output d. Edema presence ANS: B