Module 10 Exam Saunders QUESTIONS, ANSWERS
and Rationale COMPREHENSIVE VERSION
WITHTHE MOST RECENT AND VERIFIED ANSWERS
GUARANTEED PASS
The 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. 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 (PE)
d. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of
the arms
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema (PE)
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.
Decreased pulse
Decreased urine output
Increased blood pressure
,Increased respiratory rate
Decreased respiratory depth
Decreased urine output
Increased respiratory rate
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.
The nurse is reviewing medical records to assigned clients on the 7 am to 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
d. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/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.
The nurse is caring for a client who is being treated for congestive heart failure related to 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
Weight loss of 4 lb (1.8 kg) 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 signs/symptoms must be reversed if the fluid-volume
excess is to be resolved.
The 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)
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)
3.1 mEq/L (3.1 mmol/L)
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.
, The primary health care 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
Ensure that the medication is diluted in an appropriate amount of normal saline solution
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 primary 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.
The nurse notes that a client's serum potassium level is 5.8 mEq/L(5.8 mmol/L). What does the nurse
interpret this expected finding to be related to?
a. Diarrhea
b. Wound drainage
c. Addison disease
d. Heart failure being treated with loop diuretics
Addison disease
and Rationale COMPREHENSIVE VERSION
WITHTHE MOST RECENT AND VERIFIED ANSWERS
GUARANTEED PASS
The 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. 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 (PE)
d. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of
the arms
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema (PE)
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.
Decreased pulse
Decreased urine output
Increased blood pressure
,Increased respiratory rate
Decreased respiratory depth
Decreased urine output
Increased respiratory rate
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.
The nurse is reviewing medical records to assigned clients on the 7 am to 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
d. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/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.
The nurse is caring for a client who is being treated for congestive heart failure related to 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
Weight loss of 4 lb (1.8 kg) 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 signs/symptoms must be reversed if the fluid-volume
excess is to be resolved.
The 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)
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)
3.1 mEq/L (3.1 mmol/L)
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.
, The primary health care 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
Ensure that the medication is diluted in an appropriate amount of normal saline solution
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 primary 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.
The nurse notes that a client's serum potassium level is 5.8 mEq/L(5.8 mmol/L). What does the nurse
interpret this expected finding to be related to?
a. Diarrhea
b. Wound drainage
c. Addison disease
d. Heart failure being treated with loop diuretics
Addison disease
