Miami Dade College NUR 1141
medical surgical testbank exam
Terms in this set (179)
Exam 1 fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base
---
Imbalances
,1. The nurse obtains all of the
following The blood pressure is 90/40 mm
Hg. assessment data about a patient with
deficient fluid volume caused by a massive Rationale: The blood pressure indicates that the patient
may burn injury. Which of the following be developing hypovolemic shock as a result of fluid loss.
This assessment data will be of greatest will require immediate intervention to prevent the
concern? complications associated with systemic hypoperfusion.
The poor oral intake, decreased urine output, and skin
tenting all
a. indicate the need for increasing the patients fluid intake
but not as urgently as the hypotension.
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.
2. A recently admitted patient has a small decreased serum sodium
level. cell carcinoma of the lung, which is causing
the syndrome of inappropriate antidiuretic Rationale: SIADH causes water retention and a decrease
in hormone (SIADH). The nurse will monitor serum sodium level. Weight loss, increased urine output,
and carefully for elevated serum hematocrit may be associated with
excessive
loss of water, but not with SIADH and water retention.
a.
increased total urinary output.
b.
elevation of serum
hematocrit. c.
decreased serum sodium
level. d.
rapid and unexpected weight loss.
, 3.When the nurse is evaluating the fluid daily
weight. balance for a patient admitted for
hypovolemia associated with multiple Rationale: Daily weight is the most easily obtained and
draining wounds, the most accurate accurate means of assessing volume status. Skin turgor
varies assessment to include is considerably with age. Considerable excess fluid volume
may
be present before fluid moves into the interstitial space and
a. causes edema. Hourly urine outputs do not take account of
fluid intake or of fluid loss through insensible loss,
sweating, or
skin turgor. loss from the gastrointestinal tract or
wounds. b.
daily weight.
c.
presence of edema.
d.
hourly urine output.
4. When caring for an alert and oriented if the oral mucosa feels
dry. elderly patient with a history of dehydration,
the home health nurse will teach the patient Rationale: An alert, elderly patient will be able to
self-assess to increase fluid intake for signs of oral dryness such as thick oral secretions
or dry-appearing mucosa. The thirst mechanism decreases with age
a. and is not an accurate indicator of volume depletion. Many
older patients prefer to restrict fluids slightly in the evening
to
in the late evening hours. improve sleep quality. The patient will not be likely to
notice and act appropriately when changes in LOC
occur.
b.
if the oral mucosa feels
dry. c.
when the patient feels
thirsty. d.
as soon as changes in level of
consciousness (LOC) occur.
, 5.A patient is taking a potassium-wasting generalized
weakness. diuretic for treatment of hypertension. The
nurse will teach the patient to report Rationale: Generalized weakness progressing to flaccidity
is a symptoms of adverse effects such as manifestation of hypokalemia. Facial muscle spasms
might
occur with hypocalcemia. Loose stools are associated with
a. hyperkalemia. Personality changes are not associated
with electrolyte disturbances, although changes in mental
status
personality changes. are common manifestations with sodium excess or
deficit. b.
frequent loose
stools. c.
facial muscle
spasms. d.
generalized weakness.
6.Spironolactone (Aldactone), an I will drink apple juice instead of orange juice for
breakfast. aldosterone antagonist, is prescribed for a
patient as a diuretic. Which statement by the Rationale: Since spironolactone is a potassium-sparing
patient indicates that the teaching about this diuretic, patients should be taught to choose low
potassium medication has been effective? foods such as apple juice rather than foods that have
higher
levels of potassium, such as citrus fruits. Because the
patient is
a. using spironolactone as a diuretic, the nurse would not
encourage the patient to increase fluid intake. Teach
patients I will try to drink at least 8 glasses of water to avoid salt substitutes, which are high in
potassium.
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.
medical surgical testbank exam
Terms in this set (179)
Exam 1 fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base
---
Imbalances
,1. The nurse obtains all of the
following The blood pressure is 90/40 mm
Hg. assessment data about a patient with
deficient fluid volume caused by a massive Rationale: The blood pressure indicates that the patient
may burn injury. Which of the following be developing hypovolemic shock as a result of fluid loss.
This assessment data will be of greatest will require immediate intervention to prevent the
concern? complications associated with systemic hypoperfusion.
The poor oral intake, decreased urine output, and skin
tenting all
a. indicate the need for increasing the patients fluid intake
but not as urgently as the hypotension.
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.
2. A recently admitted patient has a small decreased serum sodium
level. cell carcinoma of the lung, which is causing
the syndrome of inappropriate antidiuretic Rationale: SIADH causes water retention and a decrease
in hormone (SIADH). The nurse will monitor serum sodium level. Weight loss, increased urine output,
and carefully for elevated serum hematocrit may be associated with
excessive
loss of water, but not with SIADH and water retention.
a.
increased total urinary output.
b.
elevation of serum
hematocrit. c.
decreased serum sodium
level. d.
rapid and unexpected weight loss.
, 3.When the nurse is evaluating the fluid daily
weight. balance for a patient admitted for
hypovolemia associated with multiple Rationale: Daily weight is the most easily obtained and
draining wounds, the most accurate accurate means of assessing volume status. Skin turgor
varies assessment to include is considerably with age. Considerable excess fluid volume
may
be present before fluid moves into the interstitial space and
a. causes edema. Hourly urine outputs do not take account of
fluid intake or of fluid loss through insensible loss,
sweating, or
skin turgor. loss from the gastrointestinal tract or
wounds. b.
daily weight.
c.
presence of edema.
d.
hourly urine output.
4. When caring for an alert and oriented if the oral mucosa feels
dry. elderly patient with a history of dehydration,
the home health nurse will teach the patient Rationale: An alert, elderly patient will be able to
self-assess to increase fluid intake for signs of oral dryness such as thick oral secretions
or dry-appearing mucosa. The thirst mechanism decreases with age
a. and is not an accurate indicator of volume depletion. Many
older patients prefer to restrict fluids slightly in the evening
to
in the late evening hours. improve sleep quality. The patient will not be likely to
notice and act appropriately when changes in LOC
occur.
b.
if the oral mucosa feels
dry. c.
when the patient feels
thirsty. d.
as soon as changes in level of
consciousness (LOC) occur.
, 5.A patient is taking a potassium-wasting generalized
weakness. diuretic for treatment of hypertension. The
nurse will teach the patient to report Rationale: Generalized weakness progressing to flaccidity
is a symptoms of adverse effects such as manifestation of hypokalemia. Facial muscle spasms
might
occur with hypocalcemia. Loose stools are associated with
a. hyperkalemia. Personality changes are not associated
with electrolyte disturbances, although changes in mental
status
personality changes. are common manifestations with sodium excess or
deficit. b.
frequent loose
stools. c.
facial muscle
spasms. d.
generalized weakness.
6.Spironolactone (Aldactone), an I will drink apple juice instead of orange juice for
breakfast. aldosterone antagonist, is prescribed for a
patient as a diuretic. Which statement by the Rationale: Since spironolactone is a potassium-sparing
patient indicates that the teaching about this diuretic, patients should be taught to choose low
potassium medication has been effective? foods such as apple juice rather than foods that have
higher
levels of potassium, such as citrus fruits. Because the
patient is
a. using spironolactone as a diuretic, the nurse would not
encourage the patient to increase fluid intake. Teach
patients I will try to drink at least 8 glasses of water to avoid salt substitutes, which are high in
potassium.
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.
