Exam (elaborations)
NURING HESI FUNDAMENTAL EXAMS WITH RATIONAL ANSWERS
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A nurse should plam care knowing that which client is at risk for a pottasium deficit
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The nurse should plan care knowing that which client is at risk for a potassiumdeficit? - ANSWER The client receiving nasogastric suction
Rationale:
Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places
the client at risk for hypokalemia
The nurse reviews a client's electrolyte results and notes a potassium level of 5.5
mEq/L. The nurse understands that a potassium value at this level should be noted
with which condition? - ANSWER Traumatic burn
Rationale:
A serum potassium level that exceeds 5.0 mEq/L is indicative of hyperkalemia.
Clients who experience the cellular shifting of potassium, as in the early stages of
massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory
acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or
diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.
The nurse reviews a client's electrolyte results and notes that the potassium level is
5.4 mEq/L. Which should the nurse observe for on the cardiac monitor as a result of
this laboratory value? - ANSWER Narrow, peaked T waves
Rationale:
A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac
changes include a wide, flat P wave; a prolonged PR interval; a widened QRS
complex; and narrow, peaked T waves.
"insensible fluid loss of approximately 800 mL daily." Which client is at risk for this
loss? - ANSWER Client with a fast respiratory rate
Rationale:
Sensible losses are those that the person is aware of, such as those that occur
through wound drainage, GI tract losses, and urination. Insensible losses may occur
without the person's awareness. Insensible losses occur daily through the skin and
the lungs.
The nurse is reviewing the health records of assigned clients. The nurse should plan
care knowing that which client is at the least likely risk for the development of third-
spacing? - ANSWER The client with diabetes mellitus
Rationale:
Fluid that shifts into the interstitial spaces and remains there is referred to as third-
space fluid. Common sites for third-spacing include the abdomen, pleural cavity,
peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless
because it does not circulate to provide nutrients for the cells. Risk factors include
liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery,
malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.
The nurse should plan care knowing that which client is at risk for fluid volume
deficit? - ANSWER The client with a colostomy
, rationale:
Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause
increased respirations or increased urinary output, insufficient intravenous fluid
replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, HF,
or decreased kidney function is at risk for fluid volume excess.
The nurse is caring for a client who has been taking diuretics on a long-term basis.
Which finding should the nurse expect to note as a result of this long-term use? -
ANSWER Increased specific gravity of the urine
The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The
nurse expects that this sodium level would be noted in a client with which condition?
- ANSWER The client with the syndrome of inappropriate secretion of antidiuretic
hormone (SIADH)
rationale:
Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can
occur secondary to SIADH. The client with an inadequate daily water intake, watery
diarrhea, or diabetes insipidus is at risk for hypernatremia.
The nurse is caring for a client with leukemia and notes that the client has poor skin
turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which
additional signs/symptoms should the nurse expect to note in this client if
hyponatremia is present? - ANSWER Postural blood pressure changes
Rationale:
Postural blood pressure changes occur in the client with hyponatremia. Intense thirst
and dry mucous membranes are seen in clients with hypernatremia. A slow,
bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a
rapid, thready pulse is noted.
The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory
studies are performed, and the serum calcium level is 12.0 mg/dL. Based on this
laboratory value, the nurse should take which action? - ANSWER Inform the
registered nurse of the laboratory value.
Rationale:
The normal serum calcium level ranges from 8.6 to 10.0 mg/dL. The client is
experiencing hypercalcemia, and the nurse would inform the registered nurse of the
laboratory value. Because the client is experiencing hypercalcemia, the remaining
options are incorrect actions.
The nurse reviews the client's serum calcium level and notes that the level is 8.0
mg/dL. The nurse understands which condition causes this serum calcium level? -
ANSWER Prolonged bed rest
Rationale:
The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium
level of 8.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin
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