Fluid, Electrolyte, and Acid-Base Balance Chapter 16 Exam
The nurse is caring for a client who has experienced a massive burn and is at risk for
hypovolemia. Which of the following assessment data will be of most concern to the
nurse?
a. Blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL for the past hour.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum. - ANSWER A. The blood pressure
suggests that this client is at risk for developing hypovolemic shock due to intravascular
fluid loss associated with the burn injury. This finding 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 patient's fluid intake but not as urgently as the hypotension.
A patient with small cell carcinoma of the lung develops the syndrome of inappropriate
antidiuretic hormone. The nurse should communicate to the health care provider which
assessment finding?
a. Weight gain reported by the patient
b. Serum hematocrit of 42%
c. Serum sodium level of 120 mg/dL
d. Total urinary output of 280 mL during the past 8 hours - ANSWER C. Hyponatremia is
the most significant finding to communicate. SIADH leads to water retention and a drop
in serum sodium level. Hyponatremia can result in confusion and other central nervous
system effects. A critically low value likely needs treatment. At least 30 mL/hr of urine
output indicates adequate kidney functioning. The hematocrit level is within normal
limits. Weight gain is expected with SIADH due to water retention.
The patient is admitted with hypovolemia associated with multiple draining wounds.
Which assessment would best be most accurate for the nurse to evaluate fluid balance?
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. Although very important, 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 home health nurse is providing care for an alert and oriented older adult patient
who has a history of fluid dehydration. Which of the following is the best instruction that
the nurse could provide to this patient related to fluids?
a. "Increase fluids if your mouth feels dry.
b. "More fluids are needed if you feel thirsty."
c. "Drink more fluids in the late evening hours."
d. "If you are feeling tired or confused, you need more to drink." - ANSWER A. "Increase
fluids if your mouth feels dry.
An alert, elderly patient will be able to monitor self for signs of oral dryness such as
thick oral secretions or dry-appearing mucosa. The thirst mechanism is diminished with
age and is an unreliable estimator of volume depletion. Many elderly patients prefer to
limit fluids slightly in the evening to enhance sleep. The patient will not likely recognize
and respond appropriately to changes in mental status.
The patient is receiving a potassium-wasting diuretic and complains of generalized
weakness. The nurse should BEST take which action? a. Check for facial muscle
spasms. b. Question the patient about loose stools. c. Advise the patient to avoid orange
juice with meals.
d. Ask the health care provider to order a basic metabolic panel. ANSWER D. Request
that the health care provider order a basic metabolic panel.
Hypokalemia has the symptom of generalized weakness. The nurse would want to check
the level of potassium after the health care provider has ordered the metabolic panel.
Hypocalcemia may demonstrate symptoms of spasms of the facial muscles. Orange
juice is high in the content of potassium and would be indicated to drink if the patient
had hypokalemia. Diarrhea, or loose stools, occurs with hyperkalemia.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a client. Which
The nurse is caring for a client who has experienced a massive burn and is at risk for
hypovolemia. Which of the following assessment data will be of most concern to the
nurse?
a. Blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL for the past hour.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum. - ANSWER A. The blood pressure
suggests that this client is at risk for developing hypovolemic shock due to intravascular
fluid loss associated with the burn injury. This finding 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 patient's fluid intake but not as urgently as the hypotension.
A patient with small cell carcinoma of the lung develops the syndrome of inappropriate
antidiuretic hormone. The nurse should communicate to the health care provider which
assessment finding?
a. Weight gain reported by the patient
b. Serum hematocrit of 42%
c. Serum sodium level of 120 mg/dL
d. Total urinary output of 280 mL during the past 8 hours - ANSWER C. Hyponatremia is
the most significant finding to communicate. SIADH leads to water retention and a drop
in serum sodium level. Hyponatremia can result in confusion and other central nervous
system effects. A critically low value likely needs treatment. At least 30 mL/hr of urine
output indicates adequate kidney functioning. The hematocrit level is within normal
limits. Weight gain is expected with SIADH due to water retention.
The patient is admitted with hypovolemia associated with multiple draining wounds.
Which assessment would best be most accurate for the nurse to evaluate fluid balance?
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. Although very important, 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 home health nurse is providing care for an alert and oriented older adult patient
who has a history of fluid dehydration. Which of the following is the best instruction that
the nurse could provide to this patient related to fluids?
a. "Increase fluids if your mouth feels dry.
b. "More fluids are needed if you feel thirsty."
c. "Drink more fluids in the late evening hours."
d. "If you are feeling tired or confused, you need more to drink." - ANSWER A. "Increase
fluids if your mouth feels dry.
An alert, elderly patient will be able to monitor self for signs of oral dryness such as
thick oral secretions or dry-appearing mucosa. The thirst mechanism is diminished with
age and is an unreliable estimator of volume depletion. Many elderly patients prefer to
limit fluids slightly in the evening to enhance sleep. The patient will not likely recognize
and respond appropriately to changes in mental status.
The patient is receiving a potassium-wasting diuretic and complains of generalized
weakness. The nurse should BEST take which action? a. Check for facial muscle
spasms. b. Question the patient about loose stools. c. Advise the patient to avoid orange
juice with meals.
d. Ask the health care provider to order a basic metabolic panel. ANSWER D. Request
that the health care provider order a basic metabolic panel.
Hypokalemia has the symptom of generalized weakness. The nurse would want to check
the level of potassium after the health care provider has ordered the metabolic panel.
Hypocalcemia may demonstrate symptoms of spasms of the facial muscles. Orange
juice is high in the content of potassium and would be indicated to drink if the patient
had hypokalemia. Diarrhea, or loose stools, occurs with hyperkalemia.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a client. Which
