,GCN|NSG 3100 Exam 4 | Diagnostic Testing, Elimination &
Procedures | Galen College | Latest 26/27 (PDF)
1. A client's serum sodium level is 120 mEq/L. Which body system should the nurse prioritize when
assessing this client?
A) Cardiovascular system
B) Respiratory system
C) Neurological system
D) Renal system
Correct Answer: Neurological system
Rationale: Severe hyponatremia (sodium <125 mEq/L) causes water to shift into brain cells, leading to
cerebral edema. Neurological changes such as confusion, seizures, and coma are the primary concerns
and can be life-threatening. Cardiovascular, respiratory, and renal assessments are secondary in this
situation, as the immediate risk is neurological deterioration.
2. The majority of the body's total fluid volume is located in which compartment?
A) Intravascular compartment
B) Interstitial compartment
C) Intracellular compartment
D) Transcellular compartment
Correct Answer: Intracellular compartment
Rationale: The intracellular compartment contains approximately two-thirds of the body's total water
(about 40% of total body weight). The intravascular and interstitial compartments together make up
the extracellular fluid, which is about one-third of total body water. Transcellular fluid is a small
fraction of the extracellular fluid.
3. Which client is at greatest risk for developing a fluid volume deficit?
A) A 25-year-old with pneumonia
,B) A 42-year-old with severe vomiting
C) A 68-year-old with hypertension
D) A 35-year-old with a broken arm
Correct Answer: A 42-year-old with severe vomiting
Rationale: Fluid volume deficit occurs from excessive fluid loss. Severe vomiting causes significant loss
of water and electrolytes, placing the client at high risk for hypovolemia. Pneumonia, hypertension,
and a broken arm do not typically cause the same degree of acute fluid loss. Tachycardia is one of the
first compensatory signs of fluid volume deficit.
4. A client with diarrhea for 48 hours develops fatigue, muscle weakness, and an irregular pulse.
Which laboratory finding should the nurse correlate with these signs and symptoms?
A) Serum phosphate 4.0 mEq/L
B) Serum magnesium 2.0 mEq/L
C) Serum calcium 9.5 mg/dL
D) Serum potassium 2.8 mEq/L
Correct Answer: Serum potassium 2.8 mEq/L
Rationale: Prolonged diarrhea causes significant potassium loss. Hypokalemia (normal range 3.5–5.0
mEq/L) results in fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias (irregular pulse).
The other values are within normal ranges and do not correlate with the client's symptoms.
5. A nurse is assessing a client with a vitamin D deficiency and inadequate calcium intake. Which sign
should the nurse observe for?
A) Homans sign
B) Chvostek sign
C) Kernig sign
D) Brudzinski sign
, Correct Answer: Chvostek sign
Rationale: Chvostek sign is an abnormal reaction to the stimulation of the facial nerve—twitching of
the facial muscles when the facial nerve is tapped. This indicates hypocalcemia, which can occur with
vitamin D deficiency (vitamin D is needed for calcium absorption). Homans sign is associated with
DVT, and Kernig and Brudzinski signs are associated with meningitis.
6. A client is diagnosed with fluid volume overload. Which assessment finding is most consistent with
this condition?
A) Orthostatic hypotension
B) Poor skin turgor
C) Jugular venous distention
D) Decreased urine output
Correct Answer: Jugular venous distention
Rationale: Jugular venous distention (JVD) is a sign of fluid volume overload due to increased central
venous pressure. Orthostatic hypotension, poor skin turgor, and decreased urine output are signs of
fluid volume deficit, not overload.
7. A nurse is reviewing a client's laboratory results. The client's serum potassium is 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
Procedures | Galen College | Latest 26/27 (PDF)
1. A client's serum sodium level is 120 mEq/L. Which body system should the nurse prioritize when
assessing this client?
A) Cardiovascular system
B) Respiratory system
C) Neurological system
D) Renal system
Correct Answer: Neurological system
Rationale: Severe hyponatremia (sodium <125 mEq/L) causes water to shift into brain cells, leading to
cerebral edema. Neurological changes such as confusion, seizures, and coma are the primary concerns
and can be life-threatening. Cardiovascular, respiratory, and renal assessments are secondary in this
situation, as the immediate risk is neurological deterioration.
2. The majority of the body's total fluid volume is located in which compartment?
A) Intravascular compartment
B) Interstitial compartment
C) Intracellular compartment
D) Transcellular compartment
Correct Answer: Intracellular compartment
Rationale: The intracellular compartment contains approximately two-thirds of the body's total water
(about 40% of total body weight). The intravascular and interstitial compartments together make up
the extracellular fluid, which is about one-third of total body water. Transcellular fluid is a small
fraction of the extracellular fluid.
3. Which client is at greatest risk for developing a fluid volume deficit?
A) A 25-year-old with pneumonia
,B) A 42-year-old with severe vomiting
C) A 68-year-old with hypertension
D) A 35-year-old with a broken arm
Correct Answer: A 42-year-old with severe vomiting
Rationale: Fluid volume deficit occurs from excessive fluid loss. Severe vomiting causes significant loss
of water and electrolytes, placing the client at high risk for hypovolemia. Pneumonia, hypertension,
and a broken arm do not typically cause the same degree of acute fluid loss. Tachycardia is one of the
first compensatory signs of fluid volume deficit.
4. A client with diarrhea for 48 hours develops fatigue, muscle weakness, and an irregular pulse.
Which laboratory finding should the nurse correlate with these signs and symptoms?
A) Serum phosphate 4.0 mEq/L
B) Serum magnesium 2.0 mEq/L
C) Serum calcium 9.5 mg/dL
D) Serum potassium 2.8 mEq/L
Correct Answer: Serum potassium 2.8 mEq/L
Rationale: Prolonged diarrhea causes significant potassium loss. Hypokalemia (normal range 3.5–5.0
mEq/L) results in fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias (irregular pulse).
The other values are within normal ranges and do not correlate with the client's symptoms.
5. A nurse is assessing a client with a vitamin D deficiency and inadequate calcium intake. Which sign
should the nurse observe for?
A) Homans sign
B) Chvostek sign
C) Kernig sign
D) Brudzinski sign
, Correct Answer: Chvostek sign
Rationale: Chvostek sign is an abnormal reaction to the stimulation of the facial nerve—twitching of
the facial muscles when the facial nerve is tapped. This indicates hypocalcemia, which can occur with
vitamin D deficiency (vitamin D is needed for calcium absorption). Homans sign is associated with
DVT, and Kernig and Brudzinski signs are associated with meningitis.
6. A client is diagnosed with fluid volume overload. Which assessment finding is most consistent with
this condition?
A) Orthostatic hypotension
B) Poor skin turgor
C) Jugular venous distention
D) Decreased urine output
Correct Answer: Jugular venous distention
Rationale: Jugular venous distention (JVD) is a sign of fluid volume overload due to increased central
venous pressure. Orthostatic hypotension, poor skin turgor, and decreased urine output are signs of
fluid volume deficit, not overload.
7. A nurse is reviewing a client's laboratory results. The client's serum potassium is 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
