and Correct Answers, plus Rationales | Latest
Update | Galen College Of Nursing
TABLE OF CONTENTS
# TOPIC
1 Fluid, Electrolyte & Acid-Base Balance
2 Perioperative Nursing
3 Immunity & Inflammation
4 Stress & Adaptation
5 Nursing Process & Clinical Judgment
Page 1
,Q1
A client with heart failure has gained 2 kg in 2 days. Which assessment finding is most consistent
with fluid overload?
A) Hypotension
B) *Crackles in lung bases CORRECT
C) Dry mucous membranes
D) Decreased urine output
Rationale
Fluid overload causes pulmonary congestion, evidenced by crackles; weight gain supports this.
Q2
A client with severe vomiting has a potassium level of 3.2 mEq/L. Which finding is expected?
A) Peaked T waves
B) *Muscle weakness and constipation CORRECT
C) Hypertension
D) Bradycardia
Rationale
Hypokalemia causes muscle weakness, fatigue, and decreased GI motility.
Q3
A client with renal failure has a potassium level of 6.8 mEq/L. Which action should the nurse take
first?
A) Administer furosemide
B) *Obtain a stat ECG CORRECT
C) Encourage potassium-rich foods
D) Restrict fluids
Page 2
,Rationale
Hyperkalemia can cause lethal arrhythmias; ECG is needed immediately to assess cardiac effects.
Q4
A client with hyponatremia is confused and has a seizure. Which intervention is priority?
A) Administer hypotonic IV fluids
B) *Administer hypertonic saline as ordered CORRECT
C) Restrict fluids
D) Encourage oral fluids
Rationale
Severe hyponatremia with seizures requires hypertonic saline to raise sodium levels.
Q5
A client with hypercalcemia has a calcium level of 12.5 mg/dL. Which finding is expected?
A) Positive Chvostek sign
B) *Bone pain and kidney stones CORRECT
C) Tetany
D) Hyporeflexia
Rationale
Hypercalcemia causes bone pain, renal calculi, and polyuria.
Q6
A client with hypocalcemia has a positive Trousseau sign. Which intervention is appropriate?
A) Administer calcium-lowering medications
B) *Administer calcium gluconate IV CORRECT
C) Restrict calcium intake
D) Encourage phosphate-rich foods
Page 3
, Rationale
Hypocalcemia with positive Trousseau sign requires IV calcium replacement.
Q7
A client with metabolic acidosis has a pH of 7.28 and HCO3 of 18 mEq/L. Which finding is
expected?
A) Bradycardia
B) *Kussmaul respirations CORRECT
C) Hypoventilation
D) Hypertension
Rationale
Metabolic acidosis triggers compensatory hyperventilation (Kussmaul) to blow off CO2.
Q8
A client with respiratory alkalosis has a pH of 7.50 and PaCO2 of 30 mmHg. Which condition is
most likely?
A) COPD
B) *Hyperventilation CORRECT
C) Pneumonia
D) Sedative overdose
Rationale
Respiratory alkalosis is caused by hyperventilation, which blows off CO2.
Q9
A client receiving IV potassium chloride reports pain at the IV site. Which action should the nurse
take first?
A) Stop the infusion
Page 4