,26/27NUR 201/NUR201 EXAM 1 MEDICAL-SURGICAL
NURSING I |JERSY COLLEGE| Q&A & DETAILED
RATIONALES
1. A nurse assesses a patient with fluid volume excess. Which finding is most consistent
with this condition?
A) Flat neck veins
B) Weak, thready pulse
C) Bounding peripheral pulses
D) Increased serum hematocrit
Correct Answer: Bounding peripheral pulses
Rationale: Fluid volume excess increases intravascular volume, producing stronger or
bounding pulses, jugular venous distention, peripheral edema, weight gain, hypertension,
and potentially pulmonary crackles. Flat neck veins, a weak thready pulse, and an
increased hematocrit are more consistent with fluid volume deficit because decreased
plasma volume causes hemoconcentration. Daily weight is one of the most sensitive
measures for monitoring changes in overall fluid status.
2. Which assessment is the most reliable indicator of short-term changes in a
hospitalized patient's fluid balance?
A) Daily body weight
B) Skin turgor
C) Blood pressure
D) Capillary refill
Correct Answer: Daily body weight
Rationale: Daily weight obtained under consistent conditions is the best practical indicator
of changes in total body fluid. A change of approximately 1 kg generally represents about 1
L of fluid gain or loss. Blood pressure, skin turgor, and capillary refill contribute useful
information but can be altered by age, medications, vascular disease, and other factors.
,Weights should ideally be obtained at the same time each day, using the same scale and
similar clothing.
3. A patient with severe vomiting is at greatest risk for which acid-base imbalance?
A) Respiratory acidosis
B) Metabolic alkalosis
C) Metabolic acidosis
D) Respiratory alkalosis
Correct Answer: Metabolic alkalosis
Rationale: Prolonged vomiting removes hydrochloric acid from the stomach, resulting in
loss of hydrogen ions and chloride and therefore a tendency toward metabolic alkalosis.
Respiratory abnormalities are primarily caused by changes in ventilation rather than
gastrointestinal losses. Metabolic acidosis is more commonly associated with bicarbonate
loss from severe diarrhea, renal failure, lactic acidosis, or ketoacidosis.
4. Which manifestation should the nurse consider most concerning in a patient with
severe hyperkalemia?
A) Dry mucous membranes
B) Cardiac dysrhythmias
C) Constipation
D) Increased thirst
Correct Answer: Cardiac dysrhythmias
Rationale: Potassium plays a major role in cardiac electrical conduction. Severe
hyperkalemia can produce conduction disturbances, dangerous ventricular dysrhythmias,
and cardiac arrest. Electrocardiographic abnormalities may include peaked T waves,
widening of the QRS complex, and eventually sine-wave patterns in extreme cases.
Although hyperkalemia may also cause muscle weakness or paresthesias, cardiac effects
are the immediate life-threatening concern.
, 5. Which patient is at greatest risk for hypokalemia?
A) A patient taking a potassium-sparing diuretic
B) A patient with severe renal failure
C) A patient receiving prolonged loop-diuretic therapy
D) A patient receiving a potassium supplement
Correct Answer: A patient receiving prolonged loop-diuretic therapy
Rationale: Loop diuretics increase urinary potassium loss and therefore can cause
hypokalemia, particularly when therapy is prolonged or dietary potassium intake is
inadequate. Severe renal impairment generally increases the risk of potassium retention
and hyperkalemia. Potassium-sparing diuretics and potassium supplementation also
increase rather than decrease potassium levels. Patients receiving potassium-wasting
diuretics require monitoring of electrolytes and cardiac status.
6. A patient has a serum sodium level of 119 mEq/L. Which assessment finding
requires the greatest priority?
A) Neurologic changes
B) Dry skin
C) Mild nausea
D) Decreased appetite
Correct Answer: Neurologic changes
Rationale: Severe hyponatremia can cause water to move into brain cells, leading to
cerebral edema. Confusion, altered level of consciousness, seizures, and coma are therefore
major warning signs. A sodium level of 119 mEq/L represents significant hyponatremia.
Correction must be carefully controlled because overly rapid correction of chronic
hyponatremia can cause serious neurologic injury.
7. Which clinical manifestation is most characteristic of hypernatremia?
A) Intense thirst
B) Positive Chvostek sign
NURSING I |JERSY COLLEGE| Q&A & DETAILED
RATIONALES
1. A nurse assesses a patient with fluid volume excess. Which finding is most consistent
with this condition?
A) Flat neck veins
B) Weak, thready pulse
C) Bounding peripheral pulses
D) Increased serum hematocrit
Correct Answer: Bounding peripheral pulses
Rationale: Fluid volume excess increases intravascular volume, producing stronger or
bounding pulses, jugular venous distention, peripheral edema, weight gain, hypertension,
and potentially pulmonary crackles. Flat neck veins, a weak thready pulse, and an
increased hematocrit are more consistent with fluid volume deficit because decreased
plasma volume causes hemoconcentration. Daily weight is one of the most sensitive
measures for monitoring changes in overall fluid status.
2. Which assessment is the most reliable indicator of short-term changes in a
hospitalized patient's fluid balance?
A) Daily body weight
B) Skin turgor
C) Blood pressure
D) Capillary refill
Correct Answer: Daily body weight
Rationale: Daily weight obtained under consistent conditions is the best practical indicator
of changes in total body fluid. A change of approximately 1 kg generally represents about 1
L of fluid gain or loss. Blood pressure, skin turgor, and capillary refill contribute useful
information but can be altered by age, medications, vascular disease, and other factors.
,Weights should ideally be obtained at the same time each day, using the same scale and
similar clothing.
3. A patient with severe vomiting is at greatest risk for which acid-base imbalance?
A) Respiratory acidosis
B) Metabolic alkalosis
C) Metabolic acidosis
D) Respiratory alkalosis
Correct Answer: Metabolic alkalosis
Rationale: Prolonged vomiting removes hydrochloric acid from the stomach, resulting in
loss of hydrogen ions and chloride and therefore a tendency toward metabolic alkalosis.
Respiratory abnormalities are primarily caused by changes in ventilation rather than
gastrointestinal losses. Metabolic acidosis is more commonly associated with bicarbonate
loss from severe diarrhea, renal failure, lactic acidosis, or ketoacidosis.
4. Which manifestation should the nurse consider most concerning in a patient with
severe hyperkalemia?
A) Dry mucous membranes
B) Cardiac dysrhythmias
C) Constipation
D) Increased thirst
Correct Answer: Cardiac dysrhythmias
Rationale: Potassium plays a major role in cardiac electrical conduction. Severe
hyperkalemia can produce conduction disturbances, dangerous ventricular dysrhythmias,
and cardiac arrest. Electrocardiographic abnormalities may include peaked T waves,
widening of the QRS complex, and eventually sine-wave patterns in extreme cases.
Although hyperkalemia may also cause muscle weakness or paresthesias, cardiac effects
are the immediate life-threatening concern.
, 5. Which patient is at greatest risk for hypokalemia?
A) A patient taking a potassium-sparing diuretic
B) A patient with severe renal failure
C) A patient receiving prolonged loop-diuretic therapy
D) A patient receiving a potassium supplement
Correct Answer: A patient receiving prolonged loop-diuretic therapy
Rationale: Loop diuretics increase urinary potassium loss and therefore can cause
hypokalemia, particularly when therapy is prolonged or dietary potassium intake is
inadequate. Severe renal impairment generally increases the risk of potassium retention
and hyperkalemia. Potassium-sparing diuretics and potassium supplementation also
increase rather than decrease potassium levels. Patients receiving potassium-wasting
diuretics require monitoring of electrolytes and cardiac status.
6. A patient has a serum sodium level of 119 mEq/L. Which assessment finding
requires the greatest priority?
A) Neurologic changes
B) Dry skin
C) Mild nausea
D) Decreased appetite
Correct Answer: Neurologic changes
Rationale: Severe hyponatremia can cause water to move into brain cells, leading to
cerebral edema. Confusion, altered level of consciousness, seizures, and coma are therefore
major warning signs. A sodium level of 119 mEq/L represents significant hyponatremia.
Correction must be carefully controlled because overly rapid correction of chronic
hyponatremia can cause serious neurologic injury.
7. Which clinical manifestation is most characteristic of hypernatremia?
A) Intense thirst
B) Positive Chvostek sign
