,NUR170/NUR 170 Exam 1 |
Medical-Surgical Nursing | Galen College |
26 /27Updated (PDF)
1. A client is admitted with severe vomiting and diarrhea for three days. Which assessment finding is
most consistent with fluid volume deficit?
A) Bounding peripheral pulses
B) Jugular venous distention
C) Orthostatic hypotension
D) Crackles in the lung bases
Correct Answer: Orthostatic hypotension
Rationale: Fluid volume deficit (hypovolemia) causes decreased blood volume leading to orthostatic
hypotension (drop in BP upon standing). Bounding pulses, JVD, and crackles are signs of fluid volume
overload, not deficit. The client with vomiting and diarrhea loses both water and electrolytes, leading
to dehydration.
2. A nurse is calculating intake and output for a client. Which statement accurately reflects the
relationship between fluid volume and weight?
A) 1 L of water weighs approximately 1 kg (2.2 lb)
B) 1 L of water weighs approximately 0.5 kg (1.1 lb)
C) 1 L of water weighs approximately 2 kg (4.4 lb)
D) 1 L of water weighs approximately 0.25 kg (0.55 lb)
Correct Answer: 1 L of water weighs approximately 1 kg (2.2 lb)
Rationale: One liter of water weighs approximately 1 kilogram, which equals 2.2 pounds. Daily
weights are the best indicator of fluid status because weight changes reflect fluid volume changes. A
1-kg weight gain indicates approximately 1 L of fluid retention.
,3. A client with heart failure has gained 3 kg (6.6 lb) in 24 hours. The nurse recognizes this weight gain
most likely indicates which condition?
A) Fluid volume deficit
B) Fluid volume overload
C) Adequate hydration
D) Decreased caloric intake
Correct Answer: Fluid volume overload
Rationale: A rapid weight gain of 1–2 kg or more in 24 hours indicates fluid retention (fluid volume
overload). This is a critical finding in heart failure and requires immediate intervention. Weight loss
indicates fluid volume deficit, and weight stability indicates adequate hydration.
4. A nurse is assessing a client for fluid volume deficit. Which laboratory finding supports this
diagnosis?
A) Decreased serum sodium
B) Decreased serum osmolality
C) Increased hematocrit
D) Decreased BUN
Correct Answer: Increased hematocrit
Rationale: In fluid volume deficit, the blood becomes more concentrated (hemoconcentration),
leading to an increased hematocrit, increased serum sodium, increased BUN, and increased urine
specific gravity. Decreased sodium, decreased osmolality, and decreased BUN are associated with
fluid volume overload.
5. A client with chronic kidney disease has a serum potassium level of 6.5 mEq/L. Which ECG change
does the nurse expect to observe?
A) Flattened T waves
B) Prominent U waves
, C) Tall, peaked T waves
D) ST segment depression
Correct Answer: Tall, peaked T waves
Rationale: Hyperkalemia (serum potassium > 5.0 mEq/L) causes tall, peaked T waves on ECG.
Flattened T waves and prominent U waves are associated with hypokalemia. ST segment depression is
seen with myocardial ischemia or digoxin toxicity.
6. A nurse is caring for a client with hypokalemia. Which assessment finding is most consistent with
this electrolyte imbalance?
A) Hyperactive bowel sounds
B) Muscle weakness and fatigue
C) Tachycardia and hypertension
D) Tetany and muscle spasms
Correct Answer: Muscle weakness and fatigue
Rationale: Hypokalemia causes muscle weakness, fatigue, and leg cramps due to impaired
neuromuscular function. Hyperactive bowel sounds and tachycardia are not typical. Tetany and
muscle spasms are associated with hypocalcemia and hypomagnesemia.
7. A client is prescribed furosemide (Lasix) for heart failure. Which electrolyte imbalance should the
nurse monitor for?
A) Hyperkalemia
B) Hypokalemia
C) Hypercalcemia
D) Hypermagnesemia
Correct Answer: Hypokalemia
Medical-Surgical Nursing | Galen College |
26 /27Updated (PDF)
1. A client is admitted with severe vomiting and diarrhea for three days. Which assessment finding is
most consistent with fluid volume deficit?
A) Bounding peripheral pulses
B) Jugular venous distention
C) Orthostatic hypotension
D) Crackles in the lung bases
Correct Answer: Orthostatic hypotension
Rationale: Fluid volume deficit (hypovolemia) causes decreased blood volume leading to orthostatic
hypotension (drop in BP upon standing). Bounding pulses, JVD, and crackles are signs of fluid volume
overload, not deficit. The client with vomiting and diarrhea loses both water and electrolytes, leading
to dehydration.
2. A nurse is calculating intake and output for a client. Which statement accurately reflects the
relationship between fluid volume and weight?
A) 1 L of water weighs approximately 1 kg (2.2 lb)
B) 1 L of water weighs approximately 0.5 kg (1.1 lb)
C) 1 L of water weighs approximately 2 kg (4.4 lb)
D) 1 L of water weighs approximately 0.25 kg (0.55 lb)
Correct Answer: 1 L of water weighs approximately 1 kg (2.2 lb)
Rationale: One liter of water weighs approximately 1 kilogram, which equals 2.2 pounds. Daily
weights are the best indicator of fluid status because weight changes reflect fluid volume changes. A
1-kg weight gain indicates approximately 1 L of fluid retention.
,3. A client with heart failure has gained 3 kg (6.6 lb) in 24 hours. The nurse recognizes this weight gain
most likely indicates which condition?
A) Fluid volume deficit
B) Fluid volume overload
C) Adequate hydration
D) Decreased caloric intake
Correct Answer: Fluid volume overload
Rationale: A rapid weight gain of 1–2 kg or more in 24 hours indicates fluid retention (fluid volume
overload). This is a critical finding in heart failure and requires immediate intervention. Weight loss
indicates fluid volume deficit, and weight stability indicates adequate hydration.
4. A nurse is assessing a client for fluid volume deficit. Which laboratory finding supports this
diagnosis?
A) Decreased serum sodium
B) Decreased serum osmolality
C) Increased hematocrit
D) Decreased BUN
Correct Answer: Increased hematocrit
Rationale: In fluid volume deficit, the blood becomes more concentrated (hemoconcentration),
leading to an increased hematocrit, increased serum sodium, increased BUN, and increased urine
specific gravity. Decreased sodium, decreased osmolality, and decreased BUN are associated with
fluid volume overload.
5. A client with chronic kidney disease has a serum potassium level of 6.5 mEq/L. Which ECG change
does the nurse expect to observe?
A) Flattened T waves
B) Prominent U waves
, C) Tall, peaked T waves
D) ST segment depression
Correct Answer: Tall, peaked T waves
Rationale: Hyperkalemia (serum potassium > 5.0 mEq/L) causes tall, peaked T waves on ECG.
Flattened T waves and prominent U waves are associated with hypokalemia. ST segment depression is
seen with myocardial ischemia or digoxin toxicity.
6. A nurse is caring for a client with hypokalemia. Which assessment finding is most consistent with
this electrolyte imbalance?
A) Hyperactive bowel sounds
B) Muscle weakness and fatigue
C) Tachycardia and hypertension
D) Tetany and muscle spasms
Correct Answer: Muscle weakness and fatigue
Rationale: Hypokalemia causes muscle weakness, fatigue, and leg cramps due to impaired
neuromuscular function. Hyperactive bowel sounds and tachycardia are not typical. Tetany and
muscle spasms are associated with hypocalcemia and hypomagnesemia.
7. A client is prescribed furosemide (Lasix) for heart failure. Which electrolyte imbalance should the
nurse monitor for?
A) Hyperkalemia
B) Hypokalemia
C) Hypercalcemia
D) Hypermagnesemia
Correct Answer: Hypokalemia
