Medical Surgical Test Bank 179 complete
solutions.
Medical Surgical Test Bank 179 complete
solutions.
Exam 1
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. - ANSWER 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
,Medical Surgical Test Bank 179 complete
solutions.
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. - ANSWER 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
,Medical Surgical Test Bank 179 complete
solutions.
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output. - ANSWER 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.
, Medical Surgical Test Bank 179 complete
solutions.
if the oral mucosa feels dry.
c.
when the patient feels thirsty.
d.
as soon as changes in level of consciousness (LOC) occur. - ANSWER 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
a.
personality changes.
b.
frequent loose stools.
c.
solutions.
Medical Surgical Test Bank 179 complete
solutions.
Exam 1
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. - ANSWER 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
,Medical Surgical Test Bank 179 complete
solutions.
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. - ANSWER 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
,Medical Surgical Test Bank 179 complete
solutions.
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output. - ANSWER 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.
, Medical Surgical Test Bank 179 complete
solutions.
if the oral mucosa feels dry.
c.
when the patient feels thirsty.
d.
as soon as changes in level of consciousness (LOC) occur. - ANSWER 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
a.
personality changes.
b.
frequent loose stools.
c.
