Chapter 16: Fluid, Electrolyte, and Acid-Base Balance Questions & Answers
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Chapter 16
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Chapter 16
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 prol...
Chapter 16: Fluid, Electrolyte, and Acid-
Base Balance Questions & Answers
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. - ANSWERSA. 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 patient's fluid intake but not as urgently as the hypotension
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 - ANSWERSC. 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.
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 - ANSWERSB. 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 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." - ANSWERSA. "Increase
fluids if your mouth feels dry.
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.
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. - ANSWERSD. Ask the
health care provider to order a basic metabolic panel.
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.
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." - ANSWERSD. "I will
drink apple juice instead of orange juice for breakfast."
Because spironolactone is a potassium-sparing diuretic, patients should be taught to
choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels
of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a
diuretic, the nurse would not encourage the patient to increase fluid intake. Teach
patients to avoid salt substitutes, which are high in potassium.
A newly admitted patient is diagnosed with hyponatremia. When making room
assignments, the charge nurse should take which action?
a. Assign the patient to a room near the nurse's station.
b. Place the patient in a room nearest to the water fountain.
c. Place the patient on telemetry to monitor for peaked T waves.
d. Assign the patient to a semi-private room and place an order for a low-salt diet. -
ANSWERSA. Assign the patient to a room near the nurse's station.
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