ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 19 Questions
Question 1 of 5
The nurse is caring for a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern to the nurse?
Correct Answer: A
Rationale: 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.
Question 2 of 5
The nurse is caring for a patient recently admitted with small cell carcinoma of the lung and the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments should the nurse carefully monitor?
Correct Answer: C
Rationale: SIADH causes water retention and hyponatremiaâ??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.
Question 3 of 5
The nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds. Which of the following assessments is the most accurate to evaluate volume status in this patient?
Correct Answer: B
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.
Question 4 of 5
The nurse is caring for an alert and oriented older-adult patient with a history of dehydration. Which of the following information should the home health nurse teach the patient as to when to increase fluid intake?
Correct Answer: B
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.
Question 5 of 5
The nurse is caring for a patient who is taking a potassium-wasting diuretic for treatment of hypertension. Which of the following assessment data would the nurse include in the teaching plan?
Correct Answer: D
Rationale: Lower extremity 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.