Module 10 Exam- Saunders Questions
and All Complete Solutions 2025-2026
Updated.
The 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 (PE)
d. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior
surfaces of the arms - Answer A client with new-onset of shortness of breath (SOB) and a
history of pulmonary edema (PE)
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.
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
Increased blood pressure
Increased respiratory rate
Decreased respiratory depth - Answer Decreased urine output
Increased respiratory rate
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.
,The nurse is reviewing medical records to assigned clients on the 7 am to 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
d. A 65-year-old client with a nasogastric tube attached to low suction following partial
gastrectomy - Answer An 85-year-old client receiving intravenous (IV) therapy at a rate of
100 mL/hr
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.
The nurse is caring for a client who is being treated for congestive heart failure related to
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 - Answer Weight loss of 4 lb (1.8 kg) in 24 hours
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 signs/symptoms must be reversed if the fluid-volume excess is to be
resolved.
The 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)
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) - Answer 3.1 mEq/L (3.1 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; 5.4 mEq/L (5.4 mmol/L)indicates hyperkalemia.
The primary health care 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?
a. Insert a Foley catheter in the client
b. Prepare the client for insertion of a central IV line
c. Administer the medication with the use of a macrodrip IV tubing set
d. Ensure that the medication is diluted in an appropriate amount of normal saline solution -
Answer Ensure that the medication is diluted in an appropriate amount of normal saline
solution
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 primary health care provider is
notified if the urinary 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.
The nurse notes that a client's serum potassium level is 5.8 mEq/L(5.8 mmol/L). What does the
nurse interpret this expected finding to be related to?
a. Diarrhea
b. Wound drainage
c. Addison disease
d. Heart failure being treated with loop diuretics - Answer Addison disease
, Rationale: Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. A serum
potassium level greater than 5.0 mEq/L (5.0 mmol/L)indicates hyperkalemia, and the nurse
would report the finding to the primary health care provider. Other common causes of
hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of
potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being
treated with diuretics is at risk for hypokalemia.
The nurse is caring for a client experiencing hyponatremia who was admitted to the medical-
surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte
imbalance does the nurse monitor this client? Select all that apply.
Slow pulse
Decreased urine output
Skeletal muscle weakness
Hyperactive bowel sounds
Hyperactive deep tendon reflexes - Answer Skeletal muscle weakness
Hyperactive bowel sounds
Rationale: Signs/symptoms of hyponatremia include a rapid, thready pulse; skeletal muscle
weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel
sounds; increased urine output; headache; and personality changes. The nurse must assess
these changes from baseline. If muscle weakness is detected, the nurse should immediately
check respiratory effectiveness, because ventilation depends on strength of the respiratory
muscles.
The nurse is monitoring a client with hyperparathyroidism for signs/symptoms of
hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance,
does the nurse assess the client? Select all that apply.
Paresthesias
Muscle weakness
Increased urine output
Chvostek sign
Hyperactive deep tendon reflexes - Answer Muscle weakness
Increased urine output
Rationale: Signs/symptoms of hypercalcemia include muscle weakness, diminished deep tendon
reflexes or an absence thereof, increased urine output, decreased gastrointestinal motility, and
increased heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the
Chvostek sign, and paresthesias are signs of hypocalcemia.
and All Complete Solutions 2025-2026
Updated.
The 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 (PE)
d. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior
surfaces of the arms - Answer A client with new-onset of shortness of breath (SOB) and a
history of pulmonary edema (PE)
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.
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
Increased blood pressure
Increased respiratory rate
Decreased respiratory depth - Answer Decreased urine output
Increased respiratory rate
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.
,The nurse is reviewing medical records to assigned clients on the 7 am to 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
d. A 65-year-old client with a nasogastric tube attached to low suction following partial
gastrectomy - Answer An 85-year-old client receiving intravenous (IV) therapy at a rate of
100 mL/hr
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.
The nurse is caring for a client who is being treated for congestive heart failure related to
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 - Answer Weight loss of 4 lb (1.8 kg) in 24 hours
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 signs/symptoms must be reversed if the fluid-volume excess is to be
resolved.
The 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)
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) - Answer 3.1 mEq/L (3.1 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; 5.4 mEq/L (5.4 mmol/L)indicates hyperkalemia.
The primary health care 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?
a. Insert a Foley catheter in the client
b. Prepare the client for insertion of a central IV line
c. Administer the medication with the use of a macrodrip IV tubing set
d. Ensure that the medication is diluted in an appropriate amount of normal saline solution -
Answer Ensure that the medication is diluted in an appropriate amount of normal saline
solution
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 primary health care provider is
notified if the urinary 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.
The nurse notes that a client's serum potassium level is 5.8 mEq/L(5.8 mmol/L). What does the
nurse interpret this expected finding to be related to?
a. Diarrhea
b. Wound drainage
c. Addison disease
d. Heart failure being treated with loop diuretics - Answer Addison disease
, Rationale: Adrenal insufficiency (Addison disease) is a cause of hyperkalemia. A serum
potassium level greater than 5.0 mEq/L (5.0 mmol/L)indicates hyperkalemia, and the nurse
would report the finding to the primary health care provider. Other common causes of
hyperkalemia include tissue damage, such as that in burn injuries, renal failure, and the use of
potassium-sparing diuretics. The client with diarrhea or wound drainage or the client being
treated with diuretics is at risk for hypokalemia.
The nurse is caring for a client experiencing hyponatremia who was admitted to the medical-
surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte
imbalance does the nurse monitor this client? Select all that apply.
Slow pulse
Decreased urine output
Skeletal muscle weakness
Hyperactive bowel sounds
Hyperactive deep tendon reflexes - Answer Skeletal muscle weakness
Hyperactive bowel sounds
Rationale: Signs/symptoms of hyponatremia include a rapid, thready pulse; skeletal muscle
weakness; diminished deep tendon reflexes; abdominal cramping and hyperactive bowel
sounds; increased urine output; headache; and personality changes. The nurse must assess
these changes from baseline. If muscle weakness is detected, the nurse should immediately
check respiratory effectiveness, because ventilation depends on strength of the respiratory
muscles.
The nurse is monitoring a client with hyperparathyroidism for signs/symptoms of
hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance,
does the nurse assess the client? Select all that apply.
Paresthesias
Muscle weakness
Increased urine output
Chvostek sign
Hyperactive deep tendon reflexes - Answer Muscle weakness
Increased urine output
Rationale: Signs/symptoms of hypercalcemia include muscle weakness, diminished deep tendon
reflexes or an absence thereof, increased urine output, decreased gastrointestinal motility, and
increased heart rate and blood pressure. Hyperactive deep tendon reflexes, the presence of the
Chvostek sign, and paresthesias are signs of hypocalcemia.
