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:...
questions 1 id 8482572285a client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision the nurse checks the incision and
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NURS 2362 HESI STUDY
MODULE 10
,Questions
1. ID: 8482493994A 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 client admitted with pneumonia with a fever of 100° F and some diaphoresis
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
Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible
points.
2. ID: 8482500733A 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
Content Area: Fluid and Electrolytes Awarded 2.0 points out of 2.0 possible
points.
3. ID: 8482497531A 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.
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