And Answers | Latest 2025 -2026
The nurse is caring for a client with deficient fluid volume caused by a massive burn
injury. Which of the following assessment data will be greatest concern to the nurse?
a. The blood pressure is 90/40 mmHg.
b. Urine output is 30 mL over the last house
c. Oral fluid intake is 100mL for the last hour
d. There is prolonged skin tenting over the sternum CORRECT ANSWERS The blood
pressure is 90/40
->The blood pressure indicates that the client 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 client's fluid intake
but not as urgently as the hypotension.
The nurse is caring for a client recently admitted with small cell carcinoma of the lung
and the syndrome of inappropriate antidiuretic hormone (SIADH), which of th following
assessments should the nurse carefully monitor?
a. Increased total urine output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss CORRECT ANSWERS Decreased serum sodium
level
-> SIADH causes water retention and hyponatremia—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.
The nurse is evaluating the fluids balance for a client admitted for hypovolemia
associated with multiple draining wounds. Which of the following assessments is the
most accurate to evaluate volume status in this client?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output CORRECT ANSWERS Daily weight
-> 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.