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Exam (elaborations)

NU 155 Exams 1 and 2 Prep Bundle / NU 155 Medical Surgical Nursing 1 Exams 1 and 2 Newest Practice Test Banks with 620 Questions and Correct Answers/ NU155 Exams 1 & 2 prep Bundle (Latest )

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NU 155 Exams 1 and 2 Prep Bundle / NU 155 Medical Surgical Nursing 1 Exams 1 and 2 Newest Practice Test Banks with 620 Questions and Correct Answers/ NU155 Exams 1 & 2 prep Bundle (Latest )

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NU 155 Exams 1 and 2 Prep Bundle / NU
155 Medical Surgical Nursing 1 Exams 1
and 2 Newest Practice Test Banks with
620 Questions and Correct Answers/
NU155 Exams 1 & 2 prep Bundle (Latest )
SECTION 1: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Question 1
A nurse is reviewing fluid compartments with a patient. The patient asks which
compartment contains the greatest volume of body fluid. Which response 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 matches standard fluid compartment distribution physiology .


Question 2

,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 .


Question 3
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 .


Question 4
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 .


Question 5
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 .


Question 6
A nurse is taking a patient's blood pressure manually. As the nurse pumps the cuff
above the systolic pressure for a few minutes, 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 .


SECTION 2: PERIOPERATIVE AND PACU CARE
Question 7
Following a tonsillectomy, the client should be placed in which position to
facilitate drainage of secretions and blood from the oropharynx?
• A) Supine
• B) Prone
• C) Side-lying
• D) High Fowler's
Rationale: Following a tonsillectomy, the client should be placed in a side-lying or
prone position to facilitate drainage of secretions and blood from the oropharynx,
reducing the risk of aspiration .


Question 8
In the postanesthesia care unit (PACU), which of the following assessments is the
highest priority?
• A) Level of consciousness
• B) Pain level
• C) Respiratory status
• D) Surgical site

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