HESI PN Module Exam 10
A nurse is assigned to care four clients on the medical-surgical unit. Which client
should the nurse see first on the shift assessment?
A) A client admitted with pneumonia with a fever of 100°F and some diaphoresis
B) A client with congestive heart failure with clear lu...
A nurse is assigned to care four clients on the medical-surgical unit. Which client
should the nurse see first on the shift assessment?
A) A client admitted with pneumonia with a fever of 100°F and some diaphoresis
B) A client with congestive heart failure with clear lung sounds on the previous
shift
C) A client with new-onset of shortness of breath (SOB) and a history of
pulmonary edema
D) A client undergoing long-term corticosteroid therapy with mild bruising on the
anterior surfaces of the arms - CORRECT ANSWER C) A client with new-onset of
shortness of breath and history of pulmonary edema
Rationale:
The client who should be seen first is the one with SOB and a history of pulmonary
edema. In light of such a history, SOB could indicate that fluid-volume overload
has once again developed. The client with a fever and who is diaphoretic is at risk
for insufficient fluid volume as a result of loss of fluid through the skin, but this
client is not the priority.
A client with gastroenteritis who has been vomiting and has diarrhea is admitted
to the hospital with a diagnosis of dehydration. For which clinical manifestations
that correlate with this fluid imbalance would the nurse assess the client? Select
all that apply.
A) Decreased Pulse
B) Decreased urine output
C) Increased BP
Rationale:
A client with dehydration has an increased depth and rate of respirations. The
diminished fluid volume is perceived by the body as a decreased oxygen level
(hypoxia), and increased respiration is an attempt to maintain oxygen delivery.
Other assessment findings in insufficient fluid volume are decreased urine
volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes,
concentrated urine with increased specific gravity, increased hematocrit, and
altered level of consciousness. Increased blood pressure, decreased pulse, and
increased urine output occur with fluid-volume overload.
A nurse is reviewing the medical records of the clients for the assigned 7 a.m.-7
p.m. shift. Which client will the nurse monitor most closely for excessive fluid
volume?
A) A 48yo client receiving diuretics to treat hypertension
B) A 35yo client who is vomiting undigested food after eating
C) An 85yo client receiving IV therapy at a rate of 100 mL/hr
D) A 65yo client with an NG tube attached to low suction following partial
gastrectomy - CORRECT ANSWER C) An 85yo client receiving IV therapy at a rate
of 100mL/hr
Rationale:
The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for
excessive fluid volume because of the diminished cardiovascular and renal
function that occur with aging. Other causes of excessive fluid volume include
renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to
replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion
, of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube
attached to suction is at risk for deficient fluid volume.
A nurse is caring for a client who is being treated for congestive heart failure and
has been assigned a nursing diagnosis of excessive fluid volume. Which finding
causes the nurse to determine that the client's condition has improved?
A) Dyspnea
B) 1+ edema in legs
C) Moist crackles in the lower lobes of the lungs
D) Weight loss of 4 lb in 24 hours - CORRECT ANSWER D) Weight loss of 4 lb in 24
hours
Rationale:
One sign that excessive fluid volume is resolving is loss of body weight. It is
important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb
= 1 kg). The other options listed indicate that the client is retaining fluid.
Assessment findings associated with excessive fluid volume include cough,
dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and
bounding pulse, increased central venous pressure, weight gain, edema, neck and
hand vein distention, altered level of consciousness, and decreased hematocrit.
These symptoms must be reversed if the fluid-volume excess is to be resolved.
A nurse notes that a client has ST-segment depression on the electrocardiogram
(ECG) monitor. With which potassium reading does the nurse associate this
finding?
A) 3.1 mEq/L
B) 4.2 mEq/L
C) 4.5 mEq/L
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