Saunders NCLEX – Cardiaovascular
2025/2026 Exam Questions with 100%
Correct Answers | Latest Update
The nurse is caring for a client with heart failure. On assessment, the nurse
notes that the client is dyspneic, and crackles are audible on auscultation.
What additional manifestations would the nurse expect to note in this client
if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP) - 🧠 ANSWER
✔✔Answer: 3. An increase in blood pressure and increased respirations
,Rationale: A fluid volume excess is also known as overhydration or fluid
overload and occurs when fluid intake or fluid retention exceeds the fluid
needs of the body. Assessment findings associated with fluid volume
excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated
blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck
and hand vein distention, altered level of consciousness, and decreased
hematocrit. Dry skin, flat neck and hand veins, decreased urinary output,
and decreased CVP are noted in fluid volume deficit. Weakness can be
present in either fluid volume excess or deficit.
Test-Taking Strategy(ies): Focus on the subject, fluid volume excess.
Remember that when there is more than one part to an option, all parts
need to be correct in order for the option to be correct. Think about the
pathophysiology associated with a fluid volume excess to assist in directing
you to the correct option. Also, note that the incorrect options are
comparable or alike in that each includes manifestations that reflect a
decrease.
Potassium chloride intravenously is prescribed for a client with heart failure
experiencing hypokalemia. Which actions should the nurse take to plan for
preparation and administration of the potassium? Select all that apply.
,1. Obtain an intravenous (IV) infusion pump.
2. Monitor urine output during administration.
3. Prepare the medication for bolus administration.
4. Monitor the IV site for signs of infiltration or phlebitis.
5. Ensure that the medication is diluted in the appropriate volume of fluid.
6. Ensure that the bag is labeled so that it reads the volume of potassium in
the solution. - 🧠 ANSWER ✔✔Answer: 1. Obtain an intravenous (IV)
infusion pump.
2. Monitor urine output during administration.
4. Monitor the IV site for signs of infiltration or phlebitis.
5. Ensure that the medication is diluted in the appropriate volume of fluid.
6. Ensure that the bag is labeled so that it reads the volume of potassium in
the solution.
Rationale: Potassium chloride administered intravenously must always be
diluted in IV fluid and infused via an infusion pump. Potassium chloride is
never given by bolus (IV push). Giving potassium chloride by IV push can
result in cardiac arrest. The nurse should ensure that the potassium is
COPYRIGHT©NINJANERD 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE. PRIVACY
STATEMENT. ALL RIGHTS RESERVED
3
, diluted in the appropriate amount of diluent or fluid. The IV bag containing
the potassium chloride should always be labeled with the volume of
potassium it contains. The IV site is monitored closely, because potassium
chloride is irritating to the veins and there is risk of phlebitis. In addition, the
nurse should monitor for infiltration. The nurse monitors urinary output
during administration and contacts the primary health care provider if the
urinary output is less than 30 mL/hr.
Test-Taking Strategy(ies): Focus on the subject, the preparation and
administration of potassium chloride intravenously. Think about this
procedure and the effects of potassium. Note the word bolus in option 3 to
assist in eliminating this option.
A client with atrial fibrillation who is receiving maintenance therapy of
warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis
of these laboratory values, the nurse anticipates which prescription?
1. Adding a dose of heparin sodium
2. Holding the next dose of warfarin
3. Increasing the next dose of warfarin
2025/2026 Exam Questions with 100%
Correct Answers | Latest Update
The nurse is caring for a client with heart failure. On assessment, the nurse
notes that the client is dyspneic, and crackles are audible on auscultation.
What additional manifestations would the nurse expect to note in this client
if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP) - 🧠 ANSWER
✔✔Answer: 3. An increase in blood pressure and increased respirations
,Rationale: A fluid volume excess is also known as overhydration or fluid
overload and occurs when fluid intake or fluid retention exceeds the fluid
needs of the body. Assessment findings associated with fluid volume
excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated
blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck
and hand vein distention, altered level of consciousness, and decreased
hematocrit. Dry skin, flat neck and hand veins, decreased urinary output,
and decreased CVP are noted in fluid volume deficit. Weakness can be
present in either fluid volume excess or deficit.
Test-Taking Strategy(ies): Focus on the subject, fluid volume excess.
Remember that when there is more than one part to an option, all parts
need to be correct in order for the option to be correct. Think about the
pathophysiology associated with a fluid volume excess to assist in directing
you to the correct option. Also, note that the incorrect options are
comparable or alike in that each includes manifestations that reflect a
decrease.
Potassium chloride intravenously is prescribed for a client with heart failure
experiencing hypokalemia. Which actions should the nurse take to plan for
preparation and administration of the potassium? Select all that apply.
,1. Obtain an intravenous (IV) infusion pump.
2. Monitor urine output during administration.
3. Prepare the medication for bolus administration.
4. Monitor the IV site for signs of infiltration or phlebitis.
5. Ensure that the medication is diluted in the appropriate volume of fluid.
6. Ensure that the bag is labeled so that it reads the volume of potassium in
the solution. - 🧠 ANSWER ✔✔Answer: 1. Obtain an intravenous (IV)
infusion pump.
2. Monitor urine output during administration.
4. Monitor the IV site for signs of infiltration or phlebitis.
5. Ensure that the medication is diluted in the appropriate volume of fluid.
6. Ensure that the bag is labeled so that it reads the volume of potassium in
the solution.
Rationale: Potassium chloride administered intravenously must always be
diluted in IV fluid and infused via an infusion pump. Potassium chloride is
never given by bolus (IV push). Giving potassium chloride by IV push can
result in cardiac arrest. The nurse should ensure that the potassium is
COPYRIGHT©NINJANERD 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE. PRIVACY
STATEMENT. ALL RIGHTS RESERVED
3
, diluted in the appropriate amount of diluent or fluid. The IV bag containing
the potassium chloride should always be labeled with the volume of
potassium it contains. The IV site is monitored closely, because potassium
chloride is irritating to the veins and there is risk of phlebitis. In addition, the
nurse should monitor for infiltration. The nurse monitors urinary output
during administration and contacts the primary health care provider if the
urinary output is less than 30 mL/hr.
Test-Taking Strategy(ies): Focus on the subject, the preparation and
administration of potassium chloride intravenously. Think about this
procedure and the effects of potassium. Note the word bolus in option 3 to
assist in eliminating this option.
A client with atrial fibrillation who is receiving maintenance therapy of
warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis
of these laboratory values, the nurse anticipates which prescription?
1. Adding a dose of heparin sodium
2. Holding the next dose of warfarin
3. Increasing the next dose of warfarin
