NUR 201 EXAM 2 LATEST 2026/2027
FORTIS INSTITUTE VERIFIED QUESTIONS
AND ANSWERS GRADED A|100%
ACCURATE SUMMER-FALL
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which
assessment data should be of most concern to the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for 8 hours.
d. Skin tenting over the sternum is prolonged.
ANS: B
The blood pressure indicates that the patient may be developing hypovolemic shock because of
intravascular fluid loss because of the burn injury. This finding will require immediate intervention to
prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased
urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as
urgently as the hypotension.
A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic
hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium of 120 mg/dL
c. Urinary output of 280 mL in 8 hours
d. Reported weight gain of 2.2 pounds (1 kg)
ANS: B
Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in
serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A
critically low value needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney
function. The hematocrit level is normal. Weight gain is expected with SIADH because of water
retention.
,A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate
way for the nurse to evaluate fluid balance?
a. Skin turgor
b. Daily weight
c. Urine output
d. Edema presence
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor
varies considerably with age. Considerable excess fluid volume may be present before fluid moves into
the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss
through insensible loss, sweating, or loss from the gastrointestinal tract or wounds
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration.
Which instructions should the nurse give this patient related to fluid intake?
a. "Drink more fluids in the late evening."
b. "More fluids are needed if you feel thirsty."
c. "Increase the fluids if your mouth feels dry."
d. "If you feel confused, you need more fluids."
ANS: C
An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or
dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of
volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep
quality. The patient will not be likely to notice and act appropriately when changes in level of
consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment of hypertension reports generalized
weakness. Which action is appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the
metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with
hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is
hypokalemic. Loose stools are associated with hyperkalemia.
,Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by
the patient indicates that the teaching about this medication has been effective?
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast."
ANS: D
Because spironolactone is a potassium-sparing diuretic, teach patients to choose low-potassium foods
(e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the
patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid
intake. Teach patients to avoid salt substitutes, which are high in potassium.
A patient with new-onset confusion and hyponatremia is being admitted. Which action should the
charge nurse take when making room assignments?
a. Assign the patient to a semiprivate room.
b. Assign the patient to a room near the nurse's station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves.
ANS: B
The patient should be placed near the nurse's station if confused for the staff to closely monitor the
patient. To help improve serum sodium levels, water intake is restricted. Therefore, a confused patient
should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not
hyponatremia. A confused patient could be distracting and disruptive for another patient in a
semiprivate room.
IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action
should the nurse take? a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a maximum rate of 10 mEq/hr.
c. Discontinue cardiac monitoring during the infusion.
d. Refuse to give the KCl through a peripheral venous line.
ANS: B
IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest.
KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac
monitoring should be continued while patient is receiving potassium because of the risk for
dysrhythmias.
, A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3
days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which prescribed therapy should the
nurse question?
a. Infuse 5% dextrose in water intravenously at 125 mL/hr.
b. Administer IV morphine sulfate 4 mg every 2 hours PRN.
c. Give IV metoclopramide 10 mg every 6 hours PRN for nausea.
d. Administer 3% saline intravenously at 50 mL/hr for a total of 200 mL.
ANS: A
Because the patient's gastric suction has been depleting electrolytes, the IV solution should include
electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this
patient. The other orders are appropriate for a postoperative patient with gastric suction.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for
continued mechanical ventilation. How should the nurse interpret the following arterial blood gas
results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: D
The pH indicates that the patient has alkalosis and the low PaCO2indicates a respiratory cause. The
other responses are incorrect based on the pH and the normal HCO3.
A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should
the nurse take? a. Give the prescribed PRN lorazepam (Ativan).
b. Encourage the patient to take deep slow breaths.
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Administer the prescribed fluid bolus and insulin.
ANS: D
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the
acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose
to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased
respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will
not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and
increase the level of acidosis.
An older adult patient who is malnourished presents to the emergency department with a serum
protein level of 5.2 g/dL. Which clinical manifestation should the nurse expect?
a. Pallor
b. Edema
c. Confusion
d. Restlessness
FORTIS INSTITUTE VERIFIED QUESTIONS
AND ANSWERS GRADED A|100%
ACCURATE SUMMER-FALL
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which
assessment data should be of most concern to the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for 8 hours.
d. Skin tenting over the sternum is prolonged.
ANS: B
The blood pressure indicates that the patient may be developing hypovolemic shock because of
intravascular fluid loss because of the burn injury. This finding will require immediate intervention to
prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased
urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as
urgently as the hypotension.
A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic
hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium of 120 mg/dL
c. Urinary output of 280 mL in 8 hours
d. Reported weight gain of 2.2 pounds (1 kg)
ANS: B
Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in
serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A
critically low value needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney
function. The hematocrit level is normal. Weight gain is expected with SIADH because of water
retention.
,A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate
way for the nurse to evaluate fluid balance?
a. Skin turgor
b. Daily weight
c. Urine output
d. Edema presence
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor
varies considerably with age. Considerable excess fluid volume may be present before fluid moves into
the interstitial space and causes edema. Urine outputs do not take account of fluid intake or of fluid loss
through insensible loss, sweating, or loss from the gastrointestinal tract or wounds
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration.
Which instructions should the nurse give this patient related to fluid intake?
a. "Drink more fluids in the late evening."
b. "More fluids are needed if you feel thirsty."
c. "Increase the fluids if your mouth feels dry."
d. "If you feel confused, you need more fluids."
ANS: C
An alert older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or
dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of
volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep
quality. The patient will not be likely to notice and act appropriately when changes in level of
consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment of hypertension reports generalized
weakness. Which action is appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the
metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with
hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient is
hypokalemic. Loose stools are associated with hyperkalemia.
,Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by
the patient indicates that the teaching about this medication has been effective?
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast."
ANS: D
Because spironolactone is a potassium-sparing diuretic, teach patients to choose low-potassium foods
(e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the
patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid
intake. Teach patients to avoid salt substitutes, which are high in potassium.
A patient with new-onset confusion and hyponatremia is being admitted. Which action should the
charge nurse take when making room assignments?
a. Assign the patient to a semiprivate room.
b. Assign the patient to a room near the nurse's station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves.
ANS: B
The patient should be placed near the nurse's station if confused for the staff to closely monitor the
patient. To help improve serum sodium levels, water intake is restricted. Therefore, a confused patient
should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not
hyponatremia. A confused patient could be distracting and disruptive for another patient in a
semiprivate room.
IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action
should the nurse take? a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a maximum rate of 10 mEq/hr.
c. Discontinue cardiac monitoring during the infusion.
d. Refuse to give the KCl through a peripheral venous line.
ANS: B
IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest.
KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac
monitoring should be continued while patient is receiving potassium because of the risk for
dysrhythmias.
, A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3
days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which prescribed therapy should the
nurse question?
a. Infuse 5% dextrose in water intravenously at 125 mL/hr.
b. Administer IV morphine sulfate 4 mg every 2 hours PRN.
c. Give IV metoclopramide 10 mg every 6 hours PRN for nausea.
d. Administer 3% saline intravenously at 50 mL/hr for a total of 200 mL.
ANS: A
Because the patient's gastric suction has been depleting electrolytes, the IV solution should include
electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this
patient. The other orders are appropriate for a postoperative patient with gastric suction.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for
continued mechanical ventilation. How should the nurse interpret the following arterial blood gas
results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: D
The pH indicates that the patient has alkalosis and the low PaCO2indicates a respiratory cause. The
other responses are incorrect based on the pH and the normal HCO3.
A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should
the nurse take? a. Give the prescribed PRN lorazepam (Ativan).
b. Encourage the patient to take deep slow breaths.
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Administer the prescribed fluid bolus and insulin.
ANS: D
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the
acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose
to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased
respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will
not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and
increase the level of acidosis.
An older adult patient who is malnourished presents to the emergency department with a serum
protein level of 5.2 g/dL. Which clinical manifestation should the nurse expect?
a. Pallor
b. Edema
c. Confusion
d. Restlessness
