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FLUID AND ELECTROLYTES NCLEX
QUESTIONS AND ANSWERS
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
answer- a. The blood pressure is 90/40 mm Hg.
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.
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.
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b. elevation of serum hematocrit.
c. decreased serum sodium level.
d. rapid and unexpected weight loss. - correct answer- c.
decreased serum sodium level.
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.
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 answer- b. daily weight.
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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.
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. when the patient feels thirsty.
d. as soon as changes in level of consciousness (LOC) occur. -
correct answer- b. if the oral mucosa feels dry.
An alert, elderly patient will be able to self-assess for signs of
oral dryness such as thick oral secretions or dry-appearing
mucosa. The thirst mechanism decreases with age and is not
an accurate indicator of volume depletion. Many older patients
prefer to restrict fluids slightly in the evening to improve sleep
quality. The patient will not be likely to notice and act
appropriately when changes in LOC occur.
FLUID AND ELECTROLYTES NCLEX
QUESTIONS AND ANSWERS
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
answer- a. The blood pressure is 90/40 mm Hg.
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.
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.
,2 | Page
b. elevation of serum hematocrit.
c. decreased serum sodium level.
d. rapid and unexpected weight loss. - correct answer- c.
decreased serum sodium level.
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.
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 answer- b. daily weight.
, 3 | Page
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.
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. when the patient feels thirsty.
d. as soon as changes in level of consciousness (LOC) occur. -
correct answer- b. if the oral mucosa feels dry.
An alert, elderly patient will be able to self-assess for signs of
oral dryness such as thick oral secretions or dry-appearing
mucosa. The thirst mechanism decreases with age and is not
an accurate indicator of volume depletion. Many older patients
prefer to restrict fluids slightly in the evening to improve sleep
quality. The patient will not be likely to notice and act
appropriately when changes in LOC occur.
