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1. 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.
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d.
There is prolonged skin tenting over the sternum. -
Answer-The blood pressure is 90/40 mm Hg.
Rationale: 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.
2. 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.
b.
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elevation of serum hematocrit.
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss. - Answer-decreased
serum sodium level.
Rationale: 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.
3. 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
, 4|Page
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output. - Answer-daily weight.
Rationale: 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
Med Surg Test bank ||Verified Exam!!!|| Most Recent
Exam Actual Complete Real Exam Questions And
Correct Answers (Verified Answers) Already Graded
A+ | Guaranteed Success!! Newest Exam!!!
1. 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.
,2|Page
d.
There is prolonged skin tenting over the sternum. -
Answer-The blood pressure is 90/40 mm Hg.
Rationale: 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.
2. 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.
b.
,3|Page
elevation of serum hematocrit.
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss. - Answer-decreased
serum sodium level.
Rationale: 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.
3. 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
, 4|Page
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output. - Answer-daily weight.
Rationale: 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
