,NUR242/NUR 242 Exam 2 | Medical-Surgical
Nursing | Galen College | Q & A | 2026/2027
Edition (PDF)
**1. A patient with heart failure is at risk for fluid overload. Which nursing intervention is the most
sensitive indicator of overall fluid status?**
A) Monitor urine specific gravity once per shift
B) Assess skin turgor every 4 hours
C) Weigh the patient every morning before breakfast
D) Measure oral intake each shift
Correct Answer: Weigh the patient every morning before breakfast
Rationale: Daily weight at the same time, same scale, and same clothing conditions is the most sensitive
indicator of overall fluid status. Weight changes reflect fluid shifts earlier and more accurately than skin
turgor, intake/output alone, or urine specific gravity, especially in heart failure.
**2. The nurse is caring for assigned clients at risk for fluid overload. Which clients are at greatest risk?
**
A) 22-year-old with congenital heart failure
B) 62-year-old with hepatic cirrhosis
C) 36-year-old receiving hemodialysis for CKD
D) Clients 2 and 3
Correct Answer: Clients 2 and 3
Rationale: Cirrhosis causes hypoalbuminemia and portal hypertension → third spacing/ascites/edema.
CKD on hemodialysis has impaired fluid excretion and fluid overload risk. Both conditions place clients at
high risk for fluid overload.
,**3. The nurse is caring for a patient with cardiac dysrhythmias. Which potassium level is most
concerning?**
A) 3.4 mEq/L
B) 4.0 mEq/L
C) 5.0 mEq/L
D) 6.0 mEq/L
Correct Answer: 6.0 mEq/L
Rationale: Normal potassium is 3.5-5.0 mEq/L. Hyperkalemia (K+ >5.0) can cause life-threatening cardiac
dysrhythmias, including peaked T waves, widened QRS, and cardiac arrest. A potassium level of 6.0
mEq/L requires immediate intervention.
**4. A patient is prescribed furosemide for fluid overload. Which finding indicates the medication is
effective?**
A) Weight gain of 2 lb in 24 hours
B) Decreased edema and weight loss
C) Increased blood pressure
D) Decreased urine output
Correct Answer: Decreased edema and weight loss
Rationale: Furosemide is a loop diuretic that promotes fluid excretion. Effective therapy results in
decreased edema, weight loss, and increased urine output. Daily weight monitoring is the best indicator
of fluid status.
**5. The nurse is assessing a patient with fluid overload. Which sign would the nurse expect?**
A) Flat neck veins
B) Bounding pulse
C) Decreased blood pressure
D) Dry mucous membranes
, Correct Answer: Bounding pulse
Rationale: Fluid overload causes cardiovascular symptoms including tachycardia, bounding pulse,
hypertension, decreased pulse pressure, jugular venous distention (JVD), and weight gain. Crackles in
the lungs and pitting edema are also common.
**6. The nurse is caring for a patient with fluid overload. Which laboratory finding is consistent with this
condition?**
A) Elevated serum osmolality
B) Decreased hemoglobin and hematocrit
C) Elevated BUN
D) Urine specific gravity >1.030
Correct Answer: Decreased hemoglobin and hematocrit
Rationale: In fluid overload, hemodilution leads to decreased hemoglobin and hematocrit. Serum
osmolality is decreased (<275), BUN is decreased, sodium is decreased (dilutional), and urine specific
gravity is decreased (<1.005).
**7. A patient with fluid overload is prescribed a sodium-restricted diet. Which food should the nurse
recommend?**
A) Canned soup
B) Cold baked chicken
C) Processed cheese
D) Salted nuts
Correct Answer: Cold baked chicken
Rationale: A sodium-restricted diet includes cold baked chicken, salad (no dressing), fruit, and raw
vegetables. Canned foods, processed cheese, and salted nuts are high in sodium and should be avoided.
Nursing | Galen College | Q & A | 2026/2027
Edition (PDF)
**1. A patient with heart failure is at risk for fluid overload. Which nursing intervention is the most
sensitive indicator of overall fluid status?**
A) Monitor urine specific gravity once per shift
B) Assess skin turgor every 4 hours
C) Weigh the patient every morning before breakfast
D) Measure oral intake each shift
Correct Answer: Weigh the patient every morning before breakfast
Rationale: Daily weight at the same time, same scale, and same clothing conditions is the most sensitive
indicator of overall fluid status. Weight changes reflect fluid shifts earlier and more accurately than skin
turgor, intake/output alone, or urine specific gravity, especially in heart failure.
**2. The nurse is caring for assigned clients at risk for fluid overload. Which clients are at greatest risk?
**
A) 22-year-old with congenital heart failure
B) 62-year-old with hepatic cirrhosis
C) 36-year-old receiving hemodialysis for CKD
D) Clients 2 and 3
Correct Answer: Clients 2 and 3
Rationale: Cirrhosis causes hypoalbuminemia and portal hypertension → third spacing/ascites/edema.
CKD on hemodialysis has impaired fluid excretion and fluid overload risk. Both conditions place clients at
high risk for fluid overload.
,**3. The nurse is caring for a patient with cardiac dysrhythmias. Which potassium level is most
concerning?**
A) 3.4 mEq/L
B) 4.0 mEq/L
C) 5.0 mEq/L
D) 6.0 mEq/L
Correct Answer: 6.0 mEq/L
Rationale: Normal potassium is 3.5-5.0 mEq/L. Hyperkalemia (K+ >5.0) can cause life-threatening cardiac
dysrhythmias, including peaked T waves, widened QRS, and cardiac arrest. A potassium level of 6.0
mEq/L requires immediate intervention.
**4. A patient is prescribed furosemide for fluid overload. Which finding indicates the medication is
effective?**
A) Weight gain of 2 lb in 24 hours
B) Decreased edema and weight loss
C) Increased blood pressure
D) Decreased urine output
Correct Answer: Decreased edema and weight loss
Rationale: Furosemide is a loop diuretic that promotes fluid excretion. Effective therapy results in
decreased edema, weight loss, and increased urine output. Daily weight monitoring is the best indicator
of fluid status.
**5. The nurse is assessing a patient with fluid overload. Which sign would the nurse expect?**
A) Flat neck veins
B) Bounding pulse
C) Decreased blood pressure
D) Dry mucous membranes
, Correct Answer: Bounding pulse
Rationale: Fluid overload causes cardiovascular symptoms including tachycardia, bounding pulse,
hypertension, decreased pulse pressure, jugular venous distention (JVD), and weight gain. Crackles in
the lungs and pitting edema are also common.
**6. The nurse is caring for a patient with fluid overload. Which laboratory finding is consistent with this
condition?**
A) Elevated serum osmolality
B) Decreased hemoglobin and hematocrit
C) Elevated BUN
D) Urine specific gravity >1.030
Correct Answer: Decreased hemoglobin and hematocrit
Rationale: In fluid overload, hemodilution leads to decreased hemoglobin and hematocrit. Serum
osmolality is decreased (<275), BUN is decreased, sodium is decreased (dilutional), and urine specific
gravity is decreased (<1.005).
**7. A patient with fluid overload is prescribed a sodium-restricted diet. Which food should the nurse
recommend?**
A) Canned soup
B) Cold baked chicken
C) Processed cheese
D) Salted nuts
Correct Answer: Cold baked chicken
Rationale: A sodium-restricted diet includes cold baked chicken, salad (no dressing), fruit, and raw
vegetables. Canned foods, processed cheese, and salted nuts are high in sodium and should be avoided.
