HESI Extra Credit Module 10
1. Questions
1. 1.ID: 2
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. A ...
hesi extra credit module 10 1 questions 1 1id 9476932222 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
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HESI Extra Credit Module 10
1. Questions
1. 1.ID: 9476932222
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. 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 Correct
D. 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: 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
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 9476924021
, 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
Awarded 2.0 points out of 2.0 possible points.
3. 3.ID: 9476934084
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
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9476926416
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
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
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 9476930486
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)
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;
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