NU 155 Exam 2 / NU 155 Medical
Surgical Nursing 1 Exam 2 Newest
Practice Test Bank with 220
Questions and Correct Answers/
NU155 Exam 2 prep (Latest )
Fluid, Electrolyte, and Acid-Base Balance
Q1: A nurse is reviewing fluid compartments with a patient. The patient asks which
compartment contains the greatest volume of body fluid. Which response by the
nurse is correct?
A. Intravascular fluid contains the greatest volume because it includes all blood plasma
B. Interstitial fluid contains the greatest volume because it surrounds all cells
C. Intracellular fluid contains the greatest volume, representing approximately
two-thirds of total body water
D. Extracellular fluid contains the greatest volume because it includes both intravascular
and interstitial fluids
Rationale: Intracellular fluid (ICF) comprises about two-thirds (40% of body weight) of
total body water, while extracellular fluid (ECF) comprises about one-third. This is
standard fluid compartment distribution physiology .
,Q2: A patient is admitted with severe dehydration after prolonged vomiting and
diarrhea. Which assessment finding best indicates a fluid volume deficit?
A. Distended neck veins and crackles in the lung bases
B. Bounding pulses and hypertension
C. Orthostatic hypotension, tachycardia, and dry mucous membranes
D. Dependent edema and weight gain
Rationale: Orthostatic hypotension, tachycardia, and dry mucous membranes are classic
indicators of hypovolemia and fluid volume deficit. Guidelines recommend assessing
these parameters when dehydration is suspected .
Q3: A patient with heart failure develops shortness of breath and weight gain of 3
pounds in 24 hours. The nurse recognizes these findings as indicative of which
condition?
A. Fluid volume deficit
B. Fluid volume excess
C. Metabolic acidosis
D. Respiratory alkalosis
Rationale: Rapid weight gain and pulmonary symptoms in a patient with heart failure
indicate fluid volume excess. Priority is monitoring daily weights and lung sounds to
detect fluid overload .
Q4: A patient with syndrome of inappropriate antidiuretic hormone (SIADH)
presents with confusion, headache, and lethargy. Laboratory results reveal a serum
sodium level of 128 mEq/L. Which nursing intervention is the priority?
A. Administer intravenous 3% saline rapidly to correct the sodium level
B. Restrict oral fluids and monitor neurologic status closely
C. Encourage oral sodium intake and increase fluid consumption
D. Administer potassium-sparing diuretics immediately
,Rationale: SIADH causes dilutional hyponatremia; fluid restriction is the primary
intervention. Priority is monitoring neurologic status since hyponatremia can cause
seizures .
Q5: A patient with renal failure receiving potassium supplements develops peaked
T waves on cardiac monitoring and muscle weakness. The serum potassium is 6.2
mEq/L. Which intervention should the nurse implement first?
A. Administer oral kayexalate as prescribed
B. Initiate dialysis immediately
C. Administer calcium gluconate to stabilize the cardiac membrane
D. Insert a nasogastric tube for potassium removal
Rationale: Peaked T waves indicate hyperkalemia with cardiac involvement. Calcium
gluconate is the priority to protect the myocardium from life-threatening dysrhythmias.
Kayexalate and dialysis help remove potassium but are not the first priority when cardiac
changes are present .
Q6: Lab tests revealed that the patient's sodium level [Na+] is 170 mEq/L. Which
clinical manifestation would the nurse expect to assess?
A. Tented skin turgor and thirst
B. Muscle twitching and tetany
C. Fruity breath and Kussmaul's respirations
D. Muscle weakness and paresthesia
Rationale: Hypernatremia (>145 mEq/L) causes cellular dehydration leading to thirst
and poor skin turgor. Muscle twitching and tetany more commonly occur in
hypocalcemia. Fruity breath and Kussmaul breathing indicate metabolic acidosis (e.g.,
DKA). Muscle weakness and paresthesia are associated with potassium imbalances .
, Q7: A patient with tented skin turgor, dry mucous membranes, and decreased
urinary output is under the nurse's care. Which nursing intervention should be
included in the care plan?
A. Administering I.V. and oral fluids
B. Clustering necessary activities throughout the day
C. Assessing color, odor, and amount of sputum
D. Monitoring serum albumin and total protein levels
Rationale: These findings indicate fluid volume deficit/dehydration; fluid administration
is the priority. Clustering activities is appropriate in fatigue but less urgent than
hydration. Sputum assessment is unrelated. Serum proteins are longer-term nutrition
markers .
Q8: You are taking a patient's blood pressure manually. As you pump up the cuff
above the systolic pressure for a few minutes you notice that the patient develops
a carpal spasm. Which of the following is true?
A. This is known as Trousseau's Sign and is present in patients with hypocalcemia
B. This is known as Trousseau's Sign and is present in patients with hypercalcemia
C. This is known as Chvostek's Sign
D. The patient is having a normal nervous response to an inflating blood pressure cuff
Rationale: Trousseau's sign is carpal spasm elicited by inflating a BP cuff, indicative of
hypocalcemia. Chvostek's sign is facial twitching when tapping the facial nerve, also
seen in hypocalcemia. It is not a normal nervous response .
Q9: A patient who recently had a subtotal thyroidectomy develops numbness and
tingling around the mouth and in the fingers. The nurse suspects hypocalcemia
and prepares to administer which treatment?
A. Oral calcium supplements
B. IV calcium gluconate
C. Potassium chloride
D. Magnesium sulfate
Surgical Nursing 1 Exam 2 Newest
Practice Test Bank with 220
Questions and Correct Answers/
NU155 Exam 2 prep (Latest )
Fluid, Electrolyte, and Acid-Base Balance
Q1: A nurse is reviewing fluid compartments with a patient. The patient asks which
compartment contains the greatest volume of body fluid. Which response by the
nurse is correct?
A. Intravascular fluid contains the greatest volume because it includes all blood plasma
B. Interstitial fluid contains the greatest volume because it surrounds all cells
C. Intracellular fluid contains the greatest volume, representing approximately
two-thirds of total body water
D. Extracellular fluid contains the greatest volume because it includes both intravascular
and interstitial fluids
Rationale: Intracellular fluid (ICF) comprises about two-thirds (40% of body weight) of
total body water, while extracellular fluid (ECF) comprises about one-third. This is
standard fluid compartment distribution physiology .
,Q2: A patient is admitted with severe dehydration after prolonged vomiting and
diarrhea. Which assessment finding best indicates a fluid volume deficit?
A. Distended neck veins and crackles in the lung bases
B. Bounding pulses and hypertension
C. Orthostatic hypotension, tachycardia, and dry mucous membranes
D. Dependent edema and weight gain
Rationale: Orthostatic hypotension, tachycardia, and dry mucous membranes are classic
indicators of hypovolemia and fluid volume deficit. Guidelines recommend assessing
these parameters when dehydration is suspected .
Q3: A patient with heart failure develops shortness of breath and weight gain of 3
pounds in 24 hours. The nurse recognizes these findings as indicative of which
condition?
A. Fluid volume deficit
B. Fluid volume excess
C. Metabolic acidosis
D. Respiratory alkalosis
Rationale: Rapid weight gain and pulmonary symptoms in a patient with heart failure
indicate fluid volume excess. Priority is monitoring daily weights and lung sounds to
detect fluid overload .
Q4: A patient with syndrome of inappropriate antidiuretic hormone (SIADH)
presents with confusion, headache, and lethargy. Laboratory results reveal a serum
sodium level of 128 mEq/L. Which nursing intervention is the priority?
A. Administer intravenous 3% saline rapidly to correct the sodium level
B. Restrict oral fluids and monitor neurologic status closely
C. Encourage oral sodium intake and increase fluid consumption
D. Administer potassium-sparing diuretics immediately
,Rationale: SIADH causes dilutional hyponatremia; fluid restriction is the primary
intervention. Priority is monitoring neurologic status since hyponatremia can cause
seizures .
Q5: A patient with renal failure receiving potassium supplements develops peaked
T waves on cardiac monitoring and muscle weakness. The serum potassium is 6.2
mEq/L. Which intervention should the nurse implement first?
A. Administer oral kayexalate as prescribed
B. Initiate dialysis immediately
C. Administer calcium gluconate to stabilize the cardiac membrane
D. Insert a nasogastric tube for potassium removal
Rationale: Peaked T waves indicate hyperkalemia with cardiac involvement. Calcium
gluconate is the priority to protect the myocardium from life-threatening dysrhythmias.
Kayexalate and dialysis help remove potassium but are not the first priority when cardiac
changes are present .
Q6: Lab tests revealed that the patient's sodium level [Na+] is 170 mEq/L. Which
clinical manifestation would the nurse expect to assess?
A. Tented skin turgor and thirst
B. Muscle twitching and tetany
C. Fruity breath and Kussmaul's respirations
D. Muscle weakness and paresthesia
Rationale: Hypernatremia (>145 mEq/L) causes cellular dehydration leading to thirst
and poor skin turgor. Muscle twitching and tetany more commonly occur in
hypocalcemia. Fruity breath and Kussmaul breathing indicate metabolic acidosis (e.g.,
DKA). Muscle weakness and paresthesia are associated with potassium imbalances .
, Q7: A patient with tented skin turgor, dry mucous membranes, and decreased
urinary output is under the nurse's care. Which nursing intervention should be
included in the care plan?
A. Administering I.V. and oral fluids
B. Clustering necessary activities throughout the day
C. Assessing color, odor, and amount of sputum
D. Monitoring serum albumin and total protein levels
Rationale: These findings indicate fluid volume deficit/dehydration; fluid administration
is the priority. Clustering activities is appropriate in fatigue but less urgent than
hydration. Sputum assessment is unrelated. Serum proteins are longer-term nutrition
markers .
Q8: You are taking a patient's blood pressure manually. As you pump up the cuff
above the systolic pressure for a few minutes you notice that the patient develops
a carpal spasm. Which of the following is true?
A. This is known as Trousseau's Sign and is present in patients with hypocalcemia
B. This is known as Trousseau's Sign and is present in patients with hypercalcemia
C. This is known as Chvostek's Sign
D. The patient is having a normal nervous response to an inflating blood pressure cuff
Rationale: Trousseau's sign is carpal spasm elicited by inflating a BP cuff, indicative of
hypocalcemia. Chvostek's sign is facial twitching when tapping the facial nerve, also
seen in hypocalcemia. It is not a normal nervous response .
Q9: A patient who recently had a subtotal thyroidectomy develops numbness and
tingling around the mouth and in the fingers. The nurse suspects hypocalcemia
and prepares to administer which treatment?
A. Oral calcium supplements
B. IV calcium gluconate
C. Potassium chloride
D. Magnesium sulfate
