MEDSURGE TEST BANK LATEST EDITION

MEDSURGE TEST BANK LATEST EDITION 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 patient’s fluid intake but not as urgently as the hypotension. DIF: Cognitive Level: Apply (application) REF: 292 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. DIF: Cognitive Level: Apply (application) REF: 295-296 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. DIF: Cognitive Level: Apply (application) REF: 292 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 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. DIF: Cognitive Level: Apply (application) REF: 293 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance