NUR 104/NUR104 Exam 4 V2 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is experiencing respiratory distress. Which of the
following positions should the nurse place the client in to maximize lung expansion?
A. Prone
B. Left lateral
C. Supine
D. High-Fowler’s
Correct Answer: D
Explanation: High-Fowler’s position allows for maximum chest expansion by moving the
abdominal contents away from the diaphragm. This position utilizes gravity to assist the
client’s breathing efforts and enhances oxygenation. It is the preferred intervention for
clients experiencing dyspnea or acute respiratory distress.
2. A nurse is assessing a client for fluid volume deficit. Which of the following findings should
the nurse expect?
A. Distended neck veins
B. Bounding pulse
C. Peripheral edema
D. Poor skin turgor
,Correct Answer: D
Explanation: Poor skin turgor, or tenting, is a classic sign of dehydration and fluid volume
deficit due to loss of interstitial fluid. Other signs include dry mucous membranes and
concentrated urine. Distended neck veins and edema are associated with fluid volume
excess rather than deficit.
3. A client has a potassium level of 3.2 mEq/L. Which of the following clinical manifestations
should the nurse monitor for?
A. Hyperactive bowel sounds
B. Positive Chvostek’s sign
C. Tall, peaked T waves
D. Muscle weakness
Correct Answer: D
Explanation: Hypokalemia affects the electrical conduction of muscles, often resulting in
generalized muscle weakness or leg cramps. Cardiac dysrhythmias and flattened T waves
are also common signs of low potassium levels. Peaked T waves are typically seen in
hyperkalemia, while Chvostek’s sign is linked to hypocalcemia.
4. Which of the following interventions is the highest priority when caring for a client with a
new diagnosis of hypocalcemia?
A. Implementing seizure precautions
B. Providing a high-calcium diet
, C. Administering oral calcium supplements
D. Encouraging sunlight exposure
Correct Answer: A
Explanation: Hypocalcemia can lead to neuromuscular irritability and potentially life-
threatening seizures. Safety is the priority; therefore, implementing seizure precautions
protects the client from injury during an event. While dietary changes and supplements are
necessary, they are secondary to immediate safety measures.
5. A nurse is preparing to administer a bolus enteral feeding. Which action should the nurse
take first?
A. Warm the formula in a microwave
B. Check the gastric residual volume
C. Verify the placement of the NG tube
D. Flush the tube with 50 mL of water
Correct Answer: C
Explanation: Verification of the tube’s position is the most critical first step to prevent
aspiration of formula into the lungs. Only after placement is confirmed should the nurse
proceed to check residuals or flush the tube. Standard protocol requires pH testing or X-ray
verification depending on the facility’s policy.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is experiencing respiratory distress. Which of the
following positions should the nurse place the client in to maximize lung expansion?
A. Prone
B. Left lateral
C. Supine
D. High-Fowler’s
Correct Answer: D
Explanation: High-Fowler’s position allows for maximum chest expansion by moving the
abdominal contents away from the diaphragm. This position utilizes gravity to assist the
client’s breathing efforts and enhances oxygenation. It is the preferred intervention for
clients experiencing dyspnea or acute respiratory distress.
2. A nurse is assessing a client for fluid volume deficit. Which of the following findings should
the nurse expect?
A. Distended neck veins
B. Bounding pulse
C. Peripheral edema
D. Poor skin turgor
,Correct Answer: D
Explanation: Poor skin turgor, or tenting, is a classic sign of dehydration and fluid volume
deficit due to loss of interstitial fluid. Other signs include dry mucous membranes and
concentrated urine. Distended neck veins and edema are associated with fluid volume
excess rather than deficit.
3. A client has a potassium level of 3.2 mEq/L. Which of the following clinical manifestations
should the nurse monitor for?
A. Hyperactive bowel sounds
B. Positive Chvostek’s sign
C. Tall, peaked T waves
D. Muscle weakness
Correct Answer: D
Explanation: Hypokalemia affects the electrical conduction of muscles, often resulting in
generalized muscle weakness or leg cramps. Cardiac dysrhythmias and flattened T waves
are also common signs of low potassium levels. Peaked T waves are typically seen in
hyperkalemia, while Chvostek’s sign is linked to hypocalcemia.
4. Which of the following interventions is the highest priority when caring for a client with a
new diagnosis of hypocalcemia?
A. Implementing seizure precautions
B. Providing a high-calcium diet
, C. Administering oral calcium supplements
D. Encouraging sunlight exposure
Correct Answer: A
Explanation: Hypocalcemia can lead to neuromuscular irritability and potentially life-
threatening seizures. Safety is the priority; therefore, implementing seizure precautions
protects the client from injury during an event. While dietary changes and supplements are
necessary, they are secondary to immediate safety measures.
5. A nurse is preparing to administer a bolus enteral feeding. Which action should the nurse
take first?
A. Warm the formula in a microwave
B. Check the gastric residual volume
C. Verify the placement of the NG tube
D. Flush the tube with 50 mL of water
Correct Answer: C
Explanation: Verification of the tube’s position is the most critical first step to prevent
aspiration of formula into the lungs. Only after placement is confirmed should the nurse
proceed to check residuals or flush the tube. Standard protocol requires pH testing or X-ray
verification depending on the facility’s policy.
