NURSING 2362 HESI STUDY MODULE 10 EXAM

A client with congestive heart failure with clear lung sounds on the previous shift A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct 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 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. 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: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care. (6th ed., p. 176). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment points. Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible 2. ID: 3A 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 Correct Increased blood pressure Increased respiratory rate Correct 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: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 179). St. Louis: Saunders. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment points. Content Area: Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible 3. ID: 1A 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 48-year-old client receiving diuretics to treat hypertension A 35-year old client who is vomiting undigested food after eating An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct 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. References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 2202). St. Louis: Saunders. Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient- centered collaborative care (6th ed., p. 183). St. Louis: Saunders. points. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible 4. ID: 9A 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? Dyspnea 1+ edema in the legs Moist crackles in the lower lobes of the lungs Weight loss of 4 lb in 24 hours 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: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., pp. 182, 183). St. Louis: Saunders. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation points. Content Area: Fluid and Electrolytes Awarded 1.0 points out of 1.0 possible 5. ID: 6A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which of the following serum potassium readings does the nurse associate this finding? 3.1 mEq/L Correct 4.2 mEq/L 4.5 mEq/L 5.4 mEq/L Rationale: A serum potassium level below 3.5 mEq/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