NURSING MISC Module 10 Exam (all CORRECT Answers) Download to Score an A.

A nurse is assigned to care for 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 (37.8°C) and some diaphoresis B. C. A client with congestive heart failure with clear lung sounds on the previous shift D. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct E. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms
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 fluidvolume 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.
Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, the client who should be seen first. Recall the rule of assessment of the ABCs — airway, breathing, and circulation — which means that the client experiencing SOB should take precedence over the other clients on the unit. This client’s condition could progress to respiratory arrest if the client were not assessed immediately on the basis of the signs and symptoms. Read each option and think about the client in most critical condition and review the disorders to determine which clients have the most critical needs. If you had difficulty with this question, review the various disease processes presented in this question.
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., p. 305). St. Louis: Elsevier.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological
IntegrityIntegrated Process: Nursing Process/Assessment
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical Decision Making/Clinical Judgment, Collaboration/Managing Care
Awarded 1.0 points out of 1.0 possible points.
2.ID: 1
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 Correct C. Increased blood pressure D. Increased respiratory rate Correct E. Decreased respiratory depth
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.
Test-Taking Strategy: Use the process of elimination and focus on the subject, dehydration (deficient fluid volume). Think about the pathophysiology of deficient fluid volume. Remember that the body will increase the respiratory rate in an attempt to maintain the oxygen level. If you had difficulty with this question, review the signs of insufficient fluid volume.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291-292). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Giddens Concepts: Clinical Judgment,Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes
Awarded 2.0 points out of 2.0 possible points.
3.ID: 4
A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy
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.
Test-Taking Strategy: Read the question carefully, noting that it asks for the client at risk for excessive fluid volume. Read each option and think about the fluid imbalance that could occur in each situation; in the case of the incorrect options, it is fluid-volume deficiency; the only option reflecting conditions that could result in an excess is the correct option. If you had difficulty with this question, review the causes of excessive fluid volume.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 291, 293). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes


Giddens Concepts: Care Coordination, Fluid and Electrolyte Balance
HESI Concepts: Collaboration/Managing Care, Fluid and Electrolytes
Awarded 1.0 points out of 1.0 possible points.
4.ID: 6
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 assessment finding causes the nurse to determine that the client’s condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb (1.8 kg) in 24 hours E. Correct
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.
Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that the client’s condition is improving. The only such finding is decreasing body weight. If you had difficulty with this question, review the assessment findings noted in excessive fluid volume and the signs that the condition is resolving.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 292-293). St. Louis: Mosby.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Fluid and Electrolytes


Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes
Awarded 1.0 points out of 1.0 possible points.
5.ID: 6
A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? A. 3.1 mEq/L (3.1 mmol/L) Correct B. 4.2 mEq/L (4.2 mmol/L) C. 4.5 mEq/L (4.5 mmol/L) D. 5.4 mEq/L (5.4 mmol/L) Incorrect
Rationale: A serum potassium level below 3.5 mEq/L(3.5 mmol/L) is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L (4.5 mmol/L)and 4.2 mEq/L (4.2 mmol/L)are normal potassium levels; 5.4 mEq/L (5.4 mmol/L)indicates hyperkalemia.
Test-Taking Strategy: Begin to answer this question by recalling the normal range of values for serum potassium. Next it is necessary to know that STsegment depression occurs in hypokalemia. If you had difficulty with this question, review the ECG changes that occur in hypokalemia.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 296, 791). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Fluid and Electrolytes


Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes
Awarded 0.0 points out of 1.0 possible points.
6.ID: 5
A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? A. Insert a Foley catheter in the client B. Prepare the client for insertion of a central IV line C. Administer the medication with the use of a macrodrip IV tubing set D. Ensure that the medication is diluted in an appropriate amount of normal saline solution Correct
Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. The intramuscular and subcutaneous routes of administration are not recommended because the medication cannot be adequately diluted for these routes; toxicity could result if the medication is not adequately diluted. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Saline dilution is recommended, but dextrose is avoided because it increases intracellular potassium shifting. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. The health care provider is notified if the urinary output is less than 30 mL/hr. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line.
Test-Taking Strategy: Use the process of elimination and note the strategic words “intravenous potassium chloride.” Recalling that the medication must be diluted will direct you to the correct option. If you had difficulty with this question, review the guidelines for the administration of potassium chloride.

References: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., pp. ). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology


Giddens Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence
Awarded 1.0 points out of 1.0 possible points.
7.ID: 9
A nurse notes that a client’s serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with: A. Diarrhea B. Wound drainage C. Addison disease Correct D. Heart failure being treated with loop diuretics
Rationale: A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L)indicates hyperkalemia, and the nurse would report the finding to the health care provider. Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. Other common causes of hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being treated with diuretics is at risk for hypokalemia.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they all indicate that the client is experiencing body fluid losses and therefore a loss of potassium. If you had difficulty with this question, review the risk factors associated with hyperkalemia.
Reference: Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 296, 1211). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Fluid and Electrolytes


Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes
Awarded 1.0 points out of 1.0 possible points.
8.ID: 4
A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output Incorrect C. Skeletal muscle weakness Correct D. Hyperactive bowel sounds Correct E. Hyperactive deep tendon reflexes Incorrect
Rationale: Signs of hyponatremia include a rapid, thready pulse; skeletal muscle weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel sounds; increased urine output; headache; and personality changes. The nurse must assess these changes from baseline. If muscle weakness is detected, the nurse should immediately check respiratory effectiveness, because ventilation depends on strength of the respiratory muscles.
Test-Taking Strategy: Specific knowledge of the manifestations of hyponatremia is needed to answer this question. Remember that muscle weakness and hyperactive bowel sounds are characteristics of hyponatremia. If you had difficulty with this question, review these clinical manifestations.
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 181-182). St. Louis: Saunders.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes