Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances

Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE
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.
ANS: A
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 patient’s fluid intake but not as
urgently as the hypotension.
DIF: Cognitive Level: Application REF: 310
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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.
ANS: C
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.
DIF: Cognitive Level: Comprehension REF: 307 | 310
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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.
Test Bank
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
17-2
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. 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.
DIF: Cognitive Level: Application REF: 310 TOP: Nursing Process:
Evaluation
MSC: NCLEX: Physiological Integrity
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.
ANS: B
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.
DIF: Cognitive Level: Application REF: 308 | 311
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance