ATI Fluid, Electrolyte, and Acid-Base Imbalances: Medical-Surgical Nursing: Assessment and

Management of Clinical Problems TESTBANK: Questions and Answers with Explanations (latest

Update), 100% Correct, Download to Score A

MULTIPLE CHOICE

1. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which

assessment data will be of most concern to the nurse?

a. 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 patient may be developing hypovolemic shock as a result of

intravascular fluid loss due to 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 patients fluid intake but not as urgently

as the hypotension.

2. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate

antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment

finding?

a. Reported weight gain

b. Serum hematocrit of 42%

c. Serum sodium level of 120 mg/dL

d. Total urinary output of 280 mL during past 8 hours

ANS: C

Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in

serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A

critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate

kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water

retention.

3. A patient is admitted for hypovolemia associated with multiple draining wounds. Which

assessment would be the most accurate way 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.

4. The home health nurse cares for an alert and oriented older adult patient with a history of

dehydration. Which instructions should the nurse give to this patient related to fluid intake?

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 feel lethargic or confused, you need more to drink.

ANS: A

An alert, older 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 level of

consciousness occur.

5. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of

generalized weakness. It is most appropriate for the nurse to take which action?

a. Assess for facial muscle spasms.

b. Ask the patient about loose stools.

c. Suggest that the patient avoid orange juice with meals.

d. Ask the health care provider to order a basic metabolic panel.

ANS: D

Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the

metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with

hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was

hypokalemic. Loose stools are associated with hyperkalemia.

6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which

statement by the patient 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.

ANS: D

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