NURS 3000 Midterm Questions with Complete Solutions

1. 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 of greatest concern to the nurse? 1. The blood pressure is 90/40 mm Hg. 2. Urine output is 30 mL over the last hour. 3. Oral fluid intake is 100 mL for the last 8 hours. 4. There is prolonged skin tenting over the sternum. Correct Answer-1. The blood pressure is 90/40 mmHg 2. 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 the following assessments should the nurse carefully monitor? 1. Increased total urinary output 2. Elevation of serum hematocrit 3. Decreased serum sodium level 4. Rapid and unexpected weight loss Correct Answer-2. Decreased serum sodium level 3. The nurse is evaluating the fluid 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? 1. Skin turgor 2. Daily weight