NURS 3000 Midterm Exam Questions
and All Correct Answers.
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 greatest concern to the nurse?
a. The blood pressure is 90/40 mmHg.
b. Urine output is 30 mL over the last house
c. Oral fluid intake is 100mL for the last hour
d. There is prolonged skin tenting over the sternum - Answer The blood pressure is 90/40
->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 th following assessments
should the nurse carefully monitor?
a. Increased total urine output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss - Answer Decreased serum sodium level
-> 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 fluids 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 - Answer Daily weight
-> 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 fells dry
c. When the client feels thirsty
d. As soon as changes in level or consciousness (LOC) occurs - Answer If the oral mucosa
feels dry
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 diluent for treatment of
hypertension. Which of the following assessment data would the nurse include in the teaching
plan?
a. Personality change
b. Frequent loose stools
c. Facial muscles spasms
d. Lower extremity weakness - Answer Lower extremity weakness
Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia.
Personality changes are not associated with electrolyte disturbances, although changes in
mental status are common manifestations with sodium excess or deficit.
The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client
indicates that the teaching about this medication has been effective?
a. "I will try to drink at least 8 glasses of water 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." - Answer "I will drink apple
juice instead of orange juice for breakfast"
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose low
potassium foods such as apple juice rather than foods that have higher levels of potassium, such
as citrus fruits. Because the client is using spironolactone as a diuretic, the nurse would not
encourage the client to increase fluid intake. Teach clients to avoid salt substitutes, which are
high in potassium.
and All Correct Answers.
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 greatest concern to the nurse?
a. The blood pressure is 90/40 mmHg.
b. Urine output is 30 mL over the last house
c. Oral fluid intake is 100mL for the last hour
d. There is prolonged skin tenting over the sternum - Answer The blood pressure is 90/40
->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 th following assessments
should the nurse carefully monitor?
a. Increased total urine output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss - Answer Decreased serum sodium level
-> 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 fluids 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 - Answer Daily weight
-> 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 fells dry
c. When the client feels thirsty
d. As soon as changes in level or consciousness (LOC) occurs - Answer If the oral mucosa
feels dry
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 diluent for treatment of
hypertension. Which of the following assessment data would the nurse include in the teaching
plan?
a. Personality change
b. Frequent loose stools
c. Facial muscles spasms
d. Lower extremity weakness - Answer Lower extremity weakness
Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia.
Personality changes are not associated with electrolyte disturbances, although changes in
mental status are common manifestations with sodium excess or deficit.
The nurse is teaching a client about spironolactone as a diuretic. Which statement by the client
indicates that the teaching about this medication has been effective?
a. "I will try to drink at least 8 glasses of water 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." - Answer "I will drink apple
juice instead of orange juice for breakfast"
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose low
potassium foods such as apple juice rather than foods that have higher levels of potassium, such
as citrus fruits. Because the client is using spironolactone as a diuretic, the nurse would not
encourage the client to increase fluid intake. Teach clients to avoid salt substitutes, which are
high in potassium.
