NUR 104/NUR104 Exam 3 V2 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is diagnosed with a fluid volume deficit. Which of the
following assessment findings should the nurse expect?
A. Distended neck veins
B. Orthostatic hypotension
C. Increased skin turgor
D. Bradycardia
Correct Answer: B
Explanation: Orthostatic hypotension is a common sign of fluid volume deficit due to the
lack of circulating volume. When a client changes position, the body cannot compensate for
the drop in pressure, leading to dizziness or a drop in blood pressure. Distended neck veins
and bradycardia are typically associated with fluid volume excess rather than deficit.
2. Which oxygen delivery device should the nurse use to provide a precise concentration of
oxygen to a client with chronic obstructive pulmonary disease (COPD)?
A. Simple face mask
B. Nasal cannula
C. Venturi mask
D. Non-rebreather mask
,Correct Answer: C
Explanation: The Venturi mask is the most accurate device for delivering a specific oxygen
concentration (FiO2). This is critical for clients with COPD because providing too much
oxygen can potentially suppress their respiratory drive. Other devices like the nasal
cannula or simple mask provide more variable concentrations depending on the client’s
breathing pattern.
3. A nurse is preparing to administer a cleansing enema to a client. Which position should the
nurse place the client in?
A. Supine
B. Left Sims’ position
C. Right lateral
D. High-Fowler’s
Correct Answer: B
Explanation: The Left Sims’ position allows the enema solution to flow by gravity into the
sigmoid colon and rectum. Placing the client on the left side with the right knee flexed
follows the natural anatomy of the colon. This position facilitates better distribution of the
fluid and reduces the risk of premature expulsion.
4. While assessing a client’s potassium level, the nurse notes it is 6.2 mEq/L. Which of the
following is a priority nursing intervention?
A. Encourage intake of bananas
, B. Administer potassium supplements as ordered
C. Monitor the client for cardiac arrhythmias
D. Document the finding and re-check in 24 hours
Correct Answer: C
Explanation: A potassium level of 6.2 mEq/L indicates hyperkalemia, which can lead to
life-threatening cardiac arrhythmias. The nurse must prioritize cardiac monitoring to
detect early signs of conduction disturbances. Providing potassium-rich foods or
supplements would worsen the condition, and waiting 24 hours is unsafe.
5. A nurse is documenting a client’s intake and output (I&O). The client drank 8 oz of apple
juice, 4 oz of water, and ate 6 oz of gelatin. What is the total intake in milliliters (mL)?
A. 600 mL
B. 480 mL
C. 540 mL
D. 360 mL
Correct Answer: C
Explanation: To calculate the total intake, convert ounces to milliliters by multiplying by
30 (1 oz = 30 mL). The calculation is (8 oz + 4 oz + 6 oz) = 18 oz, and 18 oz multiplied by 30
mL equals 540 mL. Gelatin is considered a liquid at room temperature and must be
included in the I&O measurement.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is diagnosed with a fluid volume deficit. Which of the
following assessment findings should the nurse expect?
A. Distended neck veins
B. Orthostatic hypotension
C. Increased skin turgor
D. Bradycardia
Correct Answer: B
Explanation: Orthostatic hypotension is a common sign of fluid volume deficit due to the
lack of circulating volume. When a client changes position, the body cannot compensate for
the drop in pressure, leading to dizziness or a drop in blood pressure. Distended neck veins
and bradycardia are typically associated with fluid volume excess rather than deficit.
2. Which oxygen delivery device should the nurse use to provide a precise concentration of
oxygen to a client with chronic obstructive pulmonary disease (COPD)?
A. Simple face mask
B. Nasal cannula
C. Venturi mask
D. Non-rebreather mask
,Correct Answer: C
Explanation: The Venturi mask is the most accurate device for delivering a specific oxygen
concentration (FiO2). This is critical for clients with COPD because providing too much
oxygen can potentially suppress their respiratory drive. Other devices like the nasal
cannula or simple mask provide more variable concentrations depending on the client’s
breathing pattern.
3. A nurse is preparing to administer a cleansing enema to a client. Which position should the
nurse place the client in?
A. Supine
B. Left Sims’ position
C. Right lateral
D. High-Fowler’s
Correct Answer: B
Explanation: The Left Sims’ position allows the enema solution to flow by gravity into the
sigmoid colon and rectum. Placing the client on the left side with the right knee flexed
follows the natural anatomy of the colon. This position facilitates better distribution of the
fluid and reduces the risk of premature expulsion.
4. While assessing a client’s potassium level, the nurse notes it is 6.2 mEq/L. Which of the
following is a priority nursing intervention?
A. Encourage intake of bananas
, B. Administer potassium supplements as ordered
C. Monitor the client for cardiac arrhythmias
D. Document the finding and re-check in 24 hours
Correct Answer: C
Explanation: A potassium level of 6.2 mEq/L indicates hyperkalemia, which can lead to
life-threatening cardiac arrhythmias. The nurse must prioritize cardiac monitoring to
detect early signs of conduction disturbances. Providing potassium-rich foods or
supplements would worsen the condition, and waiting 24 hours is unsafe.
5. A nurse is documenting a client’s intake and output (I&O). The client drank 8 oz of apple
juice, 4 oz of water, and ate 6 oz of gelatin. What is the total intake in milliliters (mL)?
A. 600 mL
B. 480 mL
C. 540 mL
D. 360 mL
Correct Answer: C
Explanation: To calculate the total intake, convert ounces to milliliters by multiplying by
30 (1 oz = 30 mL). The calculation is (8 oz + 4 oz + 6 oz) = 18 oz, and 18 oz multiplied by 30
mL equals 540 mL. Gelatin is considered a liquid at room temperature and must be
included in the I&O measurement.
