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,Exam 1 - correct ans:fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances - correct ans:---
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. - correct ans: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. - correct ans: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.
d.
hourly urine output. - correct ans: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.
c.
AND LATEST EXAM VERSION OF
(2026-2027) With Expected real and
comprehensive Questions and
Revised Correct Answers Guarantee
Pass A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
,Exam 1 - correct ans:fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances - correct ans:---
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. - correct ans: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. - correct ans: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.
d.
hourly urine output. - correct ans: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.
c.
