Lewis - Chapter 19: Fluid, Electrolyte, and Acid-Base Imbalances Questions and
Answers With Verified Solutions 2025
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?
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. - ✔✔ANS: A
The blood pressure indicates that the client 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 client's fluid intake but not as urgently
as the hypotension.
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?
a. Increased total urinary output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss - ✔✔ANS: C
SIADH causes water retention and hyponatremia—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.
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?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output - ✔✔ANS: B
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.
The nurse is caring for an alert and oriented older-adult client with a history of
dehydration. Which of the following information should the home health nurse teach the client as to
when to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the client feels thirsty
d. As soon as changes in level of consciousness (LOC) occur - ✔✔ANS: B
An alert, elderly client 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 clients prefer to restrict fluids
slightly in the evening to improve sleep quality. The client will not be likely to notice and
act appropriately when changes in LOC occur.
The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of
hypertension. Which of the following assessment data would the nurse include in the
Answers With Verified Solutions 2025
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?
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. - ✔✔ANS: A
The blood pressure indicates that the client 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 client's fluid intake but not as urgently
as the hypotension.
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?
a. Increased total urinary output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss - ✔✔ANS: C
SIADH causes water retention and hyponatremia—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.
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?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output - ✔✔ANS: B
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.
The nurse is caring for an alert and oriented older-adult client with a history of
dehydration. Which of the following information should the home health nurse teach the client as to
when to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the client feels thirsty
d. As soon as changes in level of consciousness (LOC) occur - ✔✔ANS: B
An alert, elderly client 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 clients prefer to restrict fluids
slightly in the evening to improve sleep quality. The client will not be likely to notice and
act appropriately when changes in LOC occur.
The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of
hypertension. Which of the following assessment data would the nurse include in the
