The client is admitted to the nurse’s unit with a diagnosis of heart failure. His heart is not pumping effectively, resulting in edema and coarse crackles in his lungs. The term for this condition is?

Fluid volume deficit

Fluid volume excess

Myocardial infarction

Atelectasis

Answer and Explanation

The Correct Answer is B

Choice A reason: Fluid volume deficit, or hypovolemia, involves decreased fluid volume, causing symptoms like dehydration and hypotension. Heart failure leads to fluid retention due to poor cardiac output, resulting in edema and lung crackles, which are signs of fluid overload, not deficit, making this an incorrect diagnosis.

Choice B reason: Fluid volume excess, or hypervolemia, occurs in heart failure when the heart’s reduced pumping capacity causes fluid backup, leading to edema and pulmonary congestion (crackles). This matches the client’s symptoms, as ineffective cardiac output increases venous pressure, causing fluid to accumulate in tissues and lungs.

Choice C reason: Myocardial infarction is a heart attack caused by coronary artery occlusion, leading to myocardial ischemia. While it can cause heart failure, the client’s symptoms of edema and crackles specifically indicate fluid volume excess due to heart failure, not the acute event of infarction itself.

Choice D reason: Atelectasis is lung collapse due to airway obstruction or compression, causing reduced breath sounds, not crackles. Heart failure’s pulmonary edema causes coarse crackles due to fluid in alveoli. Atelectasis does not explain the client’s edema or fluid-related symptoms, making it an incorrect choice.

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Correct Answer is C

Explanation

Choice A reason: Postoperative pain in a 47-year-old is concerning but not immediately life-threatening unless severe or accompanied by other symptoms (e.g., hemorrhage). Pain management is important, but fluid and electrolyte imbalances from vomiting and diarrhea in an elderly client pose a greater immediate risk, requiring urgent assessment.

Choice B reason: Refusal to ambulate in a 20-year-old postoperative client risks complications like thrombosis but is not an acute emergency. Immobility requires intervention, but dehydration and electrolyte imbalances in an elderly client with vomiting and diarrhea are more urgent, as they can rapidly lead to life-threatening hypovolemia.

Choice C reason: An 88-year-old with vomiting and diarrhea for 2 days is at high risk for dehydration, electrolyte imbalances, and hypovolemia, especially given age-related reduced physiological reserves. This can lead to shock or organ failure, making it the highest priority for immediate assessment to stabilize fluid and electrolyte status.

Choice D reason: A stable 60-year-old post-myocardial infarction client is not an immediate priority unless new symptoms arise. Stability suggests no acute changes in cardiac status. Vomiting and diarrhea in an elderly client pose a greater immediate risk due to potential rapid deterioration from fluid loss.

A. Hypomagnesemia B. Hyponatremia C. Hyperchloremia D. Hypokalemia

Correct Answer is A

Explanation

Choice A reason: Hypomagnesemia, low magnesium (normal 1.7–2.2 mg/dL), is indicated by the 0.8 mEq/L value. Magnesium is vital for muscle, nerve, and cardiac function. Low levels can cause tremors, seizures, and arrhythmias. The other values (sodium, chloride, potassium) are within normal ranges, making hypomagnesemia the primary imbalance.

Choice B reason: Hyponatremia, low sodium (normal 135–145 mEq/L), is not indicated, as the sodium level is 140 mEq/L, within normal limits. Hyponatremia can cause neurological symptoms like confusion, but the lab values do not support this diagnosis, and magnesium imbalance is the clear abnormality.

Choice C reason: Hyperchloremia, high chloride (normal 98–106 mEq/L), is not present, as the chloride level is 107 mEq/L, just above normal and not clinically significant. Elevated chloride may occur in dehydration or renal issues, but the primary concern here is the significantly low magnesium level.

Choice D reason: Hypokalemia, low potassium (normal 3.5–5.0 mEq/L), is not indicated, as the potassium level is 3.6 mEq/L, within normal range. Hypokalemia causes muscle weakness and arrhythmias, but the lab values point to hypomagnesemia as the primary electrolyte imbalance in this case.

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The client is admitted to the nurse’s unit with a diagnosis of heart failure. His heart is not pumping effectively, resulting in edema and coarse crackles in his lungs. The term for this condition is?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

Correct Answer is C

Explanation

As the nurse assesses a client’s laboratory values, the following are noted: Sodium 140 mEq/L, Magnesium 0.8 mEq/L, Chloride 107 mEq/L, Potassium 3.6 mEq/L. What electrolyte imbalance is indicated?

Correct Answer is A

Explanation

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