Chapter 25 High Acuity Nursing 6th Edition

Chapter 25  High Acuity Nursing 6th Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
The nurse is planning the care of a 50-year-old patient with the risk of developing fluid volume deficit. Which assessment finding would have the greatest contribution to this risk?
1. Loose bowel movement one per day
2. First-degree steam burn on hand and forearm
3. Temperature of 99.6° F
4. Diuretic therapy two doses per day
Correct Answer: 4
Rationale 1: Diarrhea does contribute to fluid volume deficit, but one loose bowel movement per day does not constitute diarrhea.
Rationale 2: Burns also can cause a fluid volume deficit but it is unlikely that a first-degree burn on the hand forearm will produce a significant amount of fluid loss.
Rationale 3: Fever does increase fluid loss, but this is a low-grade temperature whose affect would be minimal.
Rationale 4: The patient receiving two doses of diuretic therapy per day is at risk for high volumes of urine output that could increase the risk of developing a fluid volume deficit.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25-1

Question 2
Type: MCSA
A patient in the intensive care unit has developed gastrointestinal hemorrhage. The nurse would prepare to fluid resuscitate this patient with which intravenous fluid?
1. 5% dextrose and 0.45% normal saline
2. 2.5% dextrose
3. 0.45% normal saline
4. 0.9% normal saline
Correct Answer: 4
Rationale 1: The solution 5% dextrose and 0.45% normal saline is a hypertonic solution and is not the best choice for expanding the patient’s blood volume.
Rationale 2: The 2.5% dextrose is a hypotonic solution and would not help expand the patient’s blood volume.
Rationale 3: The 0.45% normal saline is a hypotonic solution and would not help expand the patient’s blood volume.
Rationale 4: The patient needs an isotonic solution to expand the blood volume. The appropriate intravenous solution is 0.9% normal saline.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 25-1

Question 3
Type: MCMA
The nurse is assessing the effectiveness of fluid replacement therapy in a patient with the nursing diagnosis of Fluid Volume Deficit. Which assessment findings would indicate the therapy is effective?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Blood pressure 90/48 mm Hg
2. Weight gain of 2 pounds since yesterday
3. Urine output increase to 40 mL per hour
4. Tenting of skin
5. Serum osmolality of 284 mOm/kg
Correct Answer: 2,3,5
Rationale 1: Low blood pressure indicates that the therapy has not been effective.
Rationale 2: Increase in weight of 2 pounds in 1 day indicates a change in fluid balance.
Rationale 3: Increase in urine output indicates improvement of fluid balance status.
Rationale 4: Tenting of skin indicates poor skin turgor and fluid volume deficit.
Rationale 5: Normal serum osmolality is 280–300 mOm/kg. Presence of normal serum osmolality indicates normal fluid volume status.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25-1

Question 4
Type: MCSA
A patient with fluid volume excess has a hemoglobin level of 9.0 mg/dL. How would the nurse explain the more likely cause of this laboratory value?
1. An undiagnosed bleeding disorder exists.
2. The patient has chronic anemia.
3. The patient has iron deficiency anemia.
4. Plasma dilution has occurred due to excess fluid.
Correct Answer: 4
Rationale 1: While this may be the case it is not the most likely reason for this lab value.
Rationale 2: While this may be the case it is not the most likely reason for this lab value.
Rationale 3: While this may be the case it is not the most likely reason for this lab value.
Rationale 4: Since this patient has fluid volume excess the most likely etiology of a low hemoglobin level is plasma dilution from excess extracellular fluid volume.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25-2