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NSG 430 EXAM 1 QUESTIONS BANK NEWEST
2025 ACTUAL EXAM COMPLETE 200+
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NSG 430 EXAM 1
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia.Which assessment data would be of most concern to the nurse?
- Urine output is 30 mL/hr.
- Blood pressure is 90/40 mm Hg.
- Oral fluid intake is 100 mL for 8 hours.
- Skin tenting over the sternum is prolonged. - CORRECT
ANSWER-Blood pressure is 90/40 mm Hg.
Rationale; The blood pressure indicates that the patient may be developing hypovolemic shock because of intravascular fluid loss from the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor 1 / 4
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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 cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would notify the health care provider about which assessment finding?
- Serum hematocrit of 42%
- Serum sodium of 120 mg/dL
- Urinary output of 280 mL in 8 hours
- Reported weight gain of 2.2 pounds (1 kg) - CORRECT
ANSWER-Serum sodium of 120 mg/dL
Rationale; 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 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 2 / 4
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with SIADH because of water retention
A patient with multiple draining wounds is admitted for hypovolemia. Which information would provide the most accurate way for the nurse to evaluate fluid balance?
- Skin turgor
- Daily weight
- Urine output
- Edema presence - CORRECT ANSWER -Daily weight
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. 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 who has a history of 3 / 4
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dehydration. Which instruction would the nurse give this patient?
- ―Drink more fluids in the late evening.‖
- ―More fluids are needed if you feel thirsty.‖
- ―Increase the fluids if your mouth feels dry.‖
- ―If you feel confused, you need more fluids.‖ - CORRECT
ANSWER-―Increase the fluids if your mouth feels dry.‖
Rationale; 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-depleting diuretic for treatment of hypertension reports generalized weakness. Which action would the nurse to take?
- Assess for facial muscle spasms.
- Ask the patient about loose stools.
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