SAUNDERS COMPREHENSIVE NCLEX
REVIEW QUESTIONS & VERIFIED
COMPLETE SOLUTIONS 100%
Fluid volume excess assessment findings - correct answer ✔✔Cardiovascular:
- bounding, increased pulse rate
- elevated bp
- distended neck and hand veins
- elevated central venous pressure
- dysrhythmias
Respiratory:
- increased RR and shallow respirations
- dyspnea
- crackles on auscultation
Neuromuscular:
- altered LOC
- headache
- visual disturbances
- skeletal muscle weakness
- paresthesias
Renal:
- increased output if kidneys can compensate, decreased output if kidneys are damaged
,Integumentary:
- pitting edema
- pale, cool skin
GI:
- increased motility
- diarrhea
- increased body weight
- liver enlargement
- ascites
Lab findings:
- decreased serum osmolality
- decreased hematocrit
- decreased BUN
- decreased Na+
- decreased urine specific gravity
Fluid volume deficit assessment findings - correct answer ✔✔Cardiovascular:
- thready, increased pulse rate
- decreased blood pressure and orthostatic hypotension
- flat neck and hand veins
- diminished peripheral pulses
- decreased central venous pressure
- dysrhythmias
,Respiratory:
- increased rate and depth of respirations
- dyspnea
Neuromuscular:
- decreased central nervous system activity, from lethargy to coma
- fever
- skeletal muscle weakness
Renal:
- decreased urine output
Integumentary:
- dry skin
- poor turgor, tenting
- dry mouth
Gastrointestinal:
- decreased motility and diminished bowel sounds
- constipation
- thirst
- decreased body weight
Lab findings:
- increased serum osmolality
, - increased hematocrit
- increased BUN
- increased Na+
- increased urine specific gravity
Hypokalemia - correct answer ✔✔- serum K+ level lower than 3.5
Assessment findings:
Cardiovascular:
- thready, weak, irregular pulse
- weak peripheral pulses
- orthostatic hypotension
- dysrhythmias
Respiratory:
- shallow, ineffective respirations
- diminished breath sounds
Neuromuscular:
- anxiety, lethargy, confusion, coma
- skeletal muscle weakness, leg cramps
- loss of tactile discrimination
- paresthesias
- deep tendon hyporeflexia
GI:
REVIEW QUESTIONS & VERIFIED
COMPLETE SOLUTIONS 100%
Fluid volume excess assessment findings - correct answer ✔✔Cardiovascular:
- bounding, increased pulse rate
- elevated bp
- distended neck and hand veins
- elevated central venous pressure
- dysrhythmias
Respiratory:
- increased RR and shallow respirations
- dyspnea
- crackles on auscultation
Neuromuscular:
- altered LOC
- headache
- visual disturbances
- skeletal muscle weakness
- paresthesias
Renal:
- increased output if kidneys can compensate, decreased output if kidneys are damaged
,Integumentary:
- pitting edema
- pale, cool skin
GI:
- increased motility
- diarrhea
- increased body weight
- liver enlargement
- ascites
Lab findings:
- decreased serum osmolality
- decreased hematocrit
- decreased BUN
- decreased Na+
- decreased urine specific gravity
Fluid volume deficit assessment findings - correct answer ✔✔Cardiovascular:
- thready, increased pulse rate
- decreased blood pressure and orthostatic hypotension
- flat neck and hand veins
- diminished peripheral pulses
- decreased central venous pressure
- dysrhythmias
,Respiratory:
- increased rate and depth of respirations
- dyspnea
Neuromuscular:
- decreased central nervous system activity, from lethargy to coma
- fever
- skeletal muscle weakness
Renal:
- decreased urine output
Integumentary:
- dry skin
- poor turgor, tenting
- dry mouth
Gastrointestinal:
- decreased motility and diminished bowel sounds
- constipation
- thirst
- decreased body weight
Lab findings:
- increased serum osmolality
, - increased hematocrit
- increased BUN
- increased Na+
- increased urine specific gravity
Hypokalemia - correct answer ✔✔- serum K+ level lower than 3.5
Assessment findings:
Cardiovascular:
- thready, weak, irregular pulse
- weak peripheral pulses
- orthostatic hypotension
- dysrhythmias
Respiratory:
- shallow, ineffective respirations
- diminished breath sounds
Neuromuscular:
- anxiety, lethargy, confusion, coma
- skeletal muscle weakness, leg cramps
- loss of tactile discrimination
- paresthesias
- deep tendon hyporeflexia
GI:
