medical surgical testbank questions and
answers summarized for 2024 series
Exam 1
fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances
---
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.
,d.
There is prolonged skin tenting over the sternum.
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.
elevation of serum hematocrit.
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss.
,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
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output.
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 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.
4. 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.
if the oral mucosa feels dry.
Rationale: 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.
5. A patient is taking a potassium-wasting diuretic for treatment of
hypertension. The nurse will teach the patient to report symptoms of
answers summarized for 2024 series
Exam 1
fluid and electrolyres
acid base
thermoregulation
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances
---
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.
,d.
There is prolonged skin tenting over the sternum.
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.
elevation of serum hematocrit.
c.
decreased serum sodium level.
d.
rapid and unexpected weight loss.
,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
a.
skin turgor.
b.
daily weight.
c.
presence of edema.
d.
hourly urine output.
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 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.
4. 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.
if the oral mucosa feels dry.
Rationale: 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.
5. A patient is taking a potassium-wasting diuretic for treatment of
hypertension. The nurse will teach the patient to report symptoms of
