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Lewis Medical-Surgical Nursing~Chapter 17 Questions and Answers (2023/2024) (Verified Answers)
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Lewis Medical-Surgical Nursing~Chapter 17 Questions and Answers (2023/2024) (Verified Answers)
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Lewis Medical-Surgical Nursing~Chapter 171.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.: Answer: a. The
blood pressure is 90/40 mm Hg.
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:
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,a. increased total urinary output.
b. elevation of serum hematocrit.
c. decreased serum sodium level.
d. rapid and unexpected weight loss.: Answer: c. decreased serum
sodium level.
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
hypervolemia 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.: Answer: b. daily weight.
Daily weight is the most easily obtained and accurate means of
assessing volume status. Skin turgor varies considerably with age.
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,Considerable excess fluid volume
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, 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.: Answer:
b. if the oral mucosa feels dry.
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
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