Hesi Study Module 10 Physiological Health Problems
Questions
1.ID: 383719769
A nurse is assigned to care for four clients on the medical-surgical unit.
... [Show More] 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 Incorrect
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
SendClient Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
2.ID: 383719781
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 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 fluidvolume 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
Content Area: Fluid and Electrolytes
Awarded 0.0 points out of 1.0 possible points.
3.ID: 383720547
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 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 causesof 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.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Awarded 0.0 points out of 1.0 possible points.
4.ID: 383721964
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?
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
Content Area: Fluid and Electrolytes
Awarded 0.0 points out of 1.0 possible points.
5.ID: 383719771
A 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 mEq/L and 4.2
mEq/L are normal potassium levels; 5.4 mEq/L indicates hyperkalemia.
Test-Taking Strategy: Begin to answer this question by recalling the normal range of values for serumpotassium. Next it is necessary to know that ST-segment depression occurs in hypokalemia. If you had
difficulty with this question, review the ECG changes that occur in hypokalemia.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care (6th ed., pp. 184, 188). St. Louis: Saunders.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Fluid and Electrolytes
Awarded 0.0 points out of 1.0 possible points.
6.ID: 383721958
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?
Insert a Foley catheter in the client
Prepare the client for insertion of a central IV line
Administer the medication with the use of a macrodrip IV tubing set
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 physician is notified if theurinary 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: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive
outcomes (8th ed., p. 154). St. Louis: Saunders.
Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care
(6th ed., pp. 188, 189). St. Louis: Saunders.
Lehne, R. (2010). Pharmacology for nursing care (7th ed., pp. 457, 458). St. Louis: Saunders.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Awarded 0.0 points out of 1.0 possible points.
7.ID: 383719761
A nurse notes that a client’s serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected
finding in the client with:
Diarrhea
Wound drainage
Addison disease Correct
Heart failure being treated with loop diuretics [Show Less]