medical surgical testbank Exam 1 - answerfluid and electrolyres acid base thermoregulation
Exam 1 - answerfluid and
... [Show More] 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.
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. -
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. -
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. -
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 adverse effects such as
a.
personality changes.
b.
frequent loose stools.
c.
facial muscle spasms.
d.
generalized weakness. -
Rationale: Generalized 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.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. 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. -
7. When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate taking?
a.
Restrict patients oral free water intake.
b.
Avoid use of electrolyte-containing drinks.
c.
Infuse a solution of 5% dextrose in 0.45% saline.
d.
Administer vasopressin (antidiuretic hormone, [ADH]). -
8. Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
a.
Administer the KCl as a rapid IV bolus.
b.
Infuse the KCl at a rate of 20 mEq/hour.
c.
Give the KCl only through a central venous line.
d.
Add no more than 40 mEq/L to a liter of IV fluid. -
9. A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question?
a.
Infuse 5% dextrose in water at 125 ml/hr.
b.
Administer IV morphine sulfate 4 mg every 2 hours PRN.
c.
Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
d.
Administer 3% saline if serum sodium drops to less than 128 mEq/L.
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