1
MEDICAL SURGICAL
TESTBANK
Exam 1 - -Correct answer-fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances - -
Correct answer----
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.
1
, 2
Oral fluid intake is 100 ml for the last 8 hours.
d.
There is prolonged skin tenting over the sternum. - -Correct
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 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.
2
, 3
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss. - -Correct 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
a.
skin turgor.
b.
daily weight.
3
, 4
c.
presence of edema.
d.
hourly urine output. - -Correct 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.
if the oral mucosa feels dry.
4
MEDICAL SURGICAL
TESTBANK
Exam 1 - -Correct answer-fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances - -
Correct answer----
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.
1
, 2
Oral fluid intake is 100 ml for the last 8 hours.
d.
There is prolonged skin tenting over the sternum. - -Correct
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 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.
2
, 3
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss. - -Correct 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
a.
skin turgor.
b.
daily weight.
3
, 4
c.
presence of edema.
d.
hourly urine output. - -Correct 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.
if the oral mucosa feels dry.
4
