1.ID: 18630147534
A nurse is assigned to care four clients on the medical-surgical unit. Which client should
the nurse see first on the shift
... [Show More] assessment?
A. A client admitted with pneumonia with a fever of 100°F 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
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 fluidvolume
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 shortness of breath 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.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Delegating/Prioritizing
D. A client undergoing long-term corticosteroid therapy with mild bruising on
the anterior surfaces of the arms
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 18630146839
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.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Fluid and Electrolytes
Awarded 2.0 points out of 2.0 possible points.
3. 3.ID: 18630147505
A nurse is reviewing the medical records of the clients for the assigned 7 a.m.–7 p.m.
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/hrCorrect
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. Look for comparable or alike options
that indicate fluid volume deficits. 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 [Show Less]