Test bank Davis Advantage for Medical-Surgical
Nursing: Making Connections to Practice 3rd
Edition by Hoffman PDF A
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
a.
personality changes.
b.
frequent loose stools.
c.
facial muscle spasms.
d.
generalized weakness.
generalized weakness.
Rationale: Generalized weakness progressing to flaccidity is a manifestation of
hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are
associated with hyperkalemia. Personality changes are not associated with electrolyte
disturbances, although changes in mental status are common manifestations with
sodium excess or deficit.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as
a diuretic. Which statement by the patient indicates that the teaching about this
medication has been effective?
a.
I will try to drink at least 8 glasses of water every day.
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.
I will drink apple juice instead of orange juice for breakfast.
Rationale: Since spironolactone is a potassium-sparing diuretic, patients should 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 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 potassium.
We have an expert-written solution to this problem!
7. When caring for a patient admitted with hyponatremia, which actions will the nurse
anticipate taking?
a.
Restrict patients oral free water intake.
b.
Avoid use of electrolyte-containing drinks.
c.
Infuse a solution of 5% dextrose in 0.45% saline.
d.
Administer vasopressin (antidiuretic hormone, [ADH]).
Restrict patients oral free water intake.
Rationale: To help improve serum sodium levels, water intake is restricted. Electrolyte-
containing beverages will improve the patients sodium level. Administration of
vasopressin or hypotonic IV solutions will decrease the serum sodium level further.
We have an expert-written solution to this problem!
,8. Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient
with severe hypokalemia. Which action should the nurse take?
a.
Administer the KCl as a rapid IV bolus.
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.
Infuse the KCl at a rate of 20 mEq/hour.
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 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, but it can be administered by this route.
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.
Nursing: Making Connections to Practice 3rd
Edition by Hoffman PDF A
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
a.
personality changes.
b.
frequent loose stools.
c.
facial muscle spasms.
d.
generalized weakness.
generalized weakness.
Rationale: Generalized weakness progressing to flaccidity is a manifestation of
hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are
associated with hyperkalemia. Personality changes are not associated with electrolyte
disturbances, although changes in mental status are common manifestations with
sodium excess or deficit.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as
a diuretic. Which statement by the patient indicates that the teaching about this
medication has been effective?
a.
I will try to drink at least 8 glasses of water every day.
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.
I will drink apple juice instead of orange juice for breakfast.
Rationale: Since spironolactone is a potassium-sparing diuretic, patients should 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 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 potassium.
We have an expert-written solution to this problem!
7. When caring for a patient admitted with hyponatremia, which actions will the nurse
anticipate taking?
a.
Restrict patients oral free water intake.
b.
Avoid use of electrolyte-containing drinks.
c.
Infuse a solution of 5% dextrose in 0.45% saline.
d.
Administer vasopressin (antidiuretic hormone, [ADH]).
Restrict patients oral free water intake.
Rationale: To help improve serum sodium levels, water intake is restricted. Electrolyte-
containing beverages will improve the patients sodium level. Administration of
vasopressin or hypotonic IV solutions will decrease the serum sodium level further.
We have an expert-written solution to this problem!
,8. Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient
with severe hypokalemia. Which action should the nurse take?
a.
Administer the KCl as a rapid IV bolus.
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.
Infuse the KCl at a rate of 20 mEq/hour.
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 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, but it can be administered by this route.
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.
