ASU NUR 325 - Exam 3 Study Guide Questions with Correct
Answers (Grade A+)
Question 1: Fluids and Electrolytes A patient with hypervolemia presents with dyspnea, crackles in the
lungs, and jugular vein distention. Which nursing intervention is most appropriate to improve the
patient's oxygenation?
a. Encourage the patient to ambulate frequently
b. Raise the head of the bed and administer oxygen as prescribed
c. Restrict oral intake completely
d. Perform passive range-of-motion exercises
Answer: B. Raise the head of the bed and administer oxygen as prescribed Rationale: Raising the head of
the bed improves lung expansion and oxygenation. Administering oxygen supports tissue perfusion.
Ambulation and ROM are important but not immediate priorities for respiratory compromise.
Question 2: Fluids and Electrolytes Which of the following are common cardiovascular manifestations
of hypervolemia? (Select all that apply)
a. Hypotension
b. Bounding pulses
c. Tachycardia
d. Jugular vein distention
e. Bradycardia
Answer: B. Bounding pulses c. Tachycardia d. Jugular vein distention Rationale: Hypervolemia increases
blood volume, leading to bounding pulses, tachycardia, and jugular vein distention. Hypotension and
bradycardia are not typical signs of fluid overload.
Question 3: Fluids and Electrolytes A patient with hypervolemia should record their ______ at the
same time each day, as it is the most accurate indicator of fluid status.
Answer: daily weight Rationale: Daily weight measurement provides a precise assessment of fluid gain or
loss, which is critical in hypervolemia management.
Question 4: Fluids and Electrolytes You are caring for a patient with hypervolemia. Place the following
interventions in order of priority based on Maslow's hierarchy and immediate patient safety: Monitor
electrolyte levels Raise the head of the bed Administer prescribed diuretics Assess lung sounds for
crackles and dyspnea
Answer: 1. Raise the head of the bed - promotes oxygenation immediately 2. Assess lung sounds identifies
severity of fluid overload and respiratory compromise 3. Administer prescribed diuretics - reduces fluid
overload after airway is addressed 4. Monitor electrolyte levels - ensures safety during fluid removal
Rationale: Airway and breathing take priority over medications and labs in hypervolemia.
Page 1
,Question 5: Fluids and Electrolytes Which lab value should the nurse monitor closely in a patient
receiving loop diuretics for hypervolemia?
a. Sodium and potassium
b. Hemoglobin and hematocrit
c. Platelet count
d. Blood glucose
Answer: A. Sodium and potassium Rationale: Loop diuretics can cause electrolyte imbalances, especially
sodium and potassium, which can affect cardiac and neuromuscular function.
Question 6: Fluids and Electrolytes Patients with hypervolemia should limit intake of ______ to help
prevent fluid retention.
Answer: sodium Rationale: Sodium increases fluid retention by osmosis; limiting sodium helps reduce
edema and blood pressure in hypervolemia.
Question 7: Fluids and Electrolytes Which of the following are appropriate client teaching points for a
patient with hypervolemia? (Select all that apply)
a. Measure and record all fluid intake and output
b. Maintain high-sodium diet to prevent hyponatremia
c. Report rapid weight gain (>2-3 lb/day or 5 lb/week)
d. Perform strenuous exercise to reduce edema
e. Follow fluid restrictions as prescribed
Answer: A. Measure and record all fluid intake and output c. Report rapid weight gain (>2-3 lb/day or 5
lb/week) e. Follow fluid restrictions as prescribed Rationale: Monitoring I&O and weight helps detect fluid
overload early. Fluid restriction reduces excess fluid accumulation. High-sodium diet and strenuous
exercise are not appropriate interventions.
Question 8: Fluids and Electrolytes A patient with liver disease and hypervolemia has ascites, edema,
and bulging neck veins. Which assessments indicate worsening fluid overload? (Select all that apply)
a. Oxygen saturation drops from 96% to 90%
b. Crackles heard in both lung bases
c. Capillary refill < 2 seconds
d. Rapid weight gain of 4 lb in one day
e. Bounding peripheral pulses
Answer: A. Oxygen saturation drops from 96% to 90% b. Crackles heard in both lung bases d. Rapid weight
gain of 4 lb in one day e. Bounding peripheral pulses Rationale: Hypoxia (low O₂ saturation), pulmonary
crackles, rapid weight gain, and bounding pulses indicate worsening fluid overload. Normal capillary refill
(<2 seconds) does not indicate impaired perfusion.
Page 2
,Question 9: Fluids and Electrolytes A patient with hypovolemia presents with dizziness, tachycardia,
and low blood pressure. Which nursing intervention is most appropriate to improve perfusion?
a. Encourage the patient to ambulate frequently
b. Administer oral fluids only
c. Place the patient in a supine position and initiate IV fluids as prescribed
d. Restrict sodium intake
Answer: C. Place the patient in a supine position and initiate IV fluids as prescribed Rationale: Placing the
patient supine helps improve blood flow to vital organs. Administering IV fluids corrects volume deficit and
improves perfusion. Ambulation may worsen hypotension; restricting sodium does not address acute
hypovolemia.
Question 10: Fluids and Electrolytes Which of the following are common cardiovascular manifestations
of hypovolemia? (Select all that apply)
a. Hypotension, especially orthostatic
b. Bounding pulses
c. Tachycardia
d. Weak, thready pulses
e. Bradycardia
Answer: A. Hypotension, especially orthostatic c. Tachycardia d. Weak, thready pulses Rationale:
Hypovolemia decreases circulating volume, causing hypotension, tachycardia, and weak thready pulses.
Bounding pulses and bradycardia are not typical.
Question 11: Fluids and Electrolytes A patient with hypovolemia is dizzy, hypotensive, and has cool,
clammy skin. Place the following nursing actions in order of priority: Administer IV fluids as
prescribed Monitor vital signs Assess mental status and peripheral perfusion Encourage oral fluid
intake
Answer: 1. Administer IV fluids as prescribed - immediate volume replacement is critical 2. Monitor vital
signs - assess effectiveness of intervention 3. Assess mental status and peripheral perfusion - monitor
perfusion improvement 4. Encourage oral fluid intake - secondary support after stabilization Rationale:
Fluid replacement and stabilization take priority over oral intake.
Question 12: Fluids and Electrolytes Which lab values are important to monitor in a patient with
hypovolemia?
a. Electrolytes, BUN, creatinine, hematocrit
b. Blood glucose and platelets
c. Lipid profile and liver function tests
d. Coagulation panel
Answer: A. Electrolytes, BUN, creatinine, hematocrit Rationale: Hypovolemia affects renal function and
electrolyte balance. Labs help assess fluid loss severity and guide IV therapy.
Page 3
, Question 13: Fluids and Electrolytes Which of the following are early signs of dehydration in a patient
with hypovolemia?
a. Bounding pulses, edema, and shortness of breath
b. Weight gain, jugular vein distention, and crackles in lungs
c. Bradycardia, hypotension, and cool, clammy skin
d. Dizziness, dry mouth, and decreased urine output
Answer: D. Dizziness, dry mouth, and decreased urine output Rationale: Early signs of dehydration include
dizziness, dry mouth, and decreased urine output due to reduced circulating volume. Bounding pulses,
edema, and lung congestion are signs of hypervolemia. Bradycardia is not typical in hypovolemia;
hypotension and cool, clammy skin appear later in severe cases.
Question 14: Fluids and Electrolytes Which of the following are appropriate client teaching points for a
patient with hypovolemia? (Select all that apply)
a. Record all fluid intake and output
b. Monitor daily weight
c. Encourage oral fluid intake unless contraindicated
d. Limit fluid intake to prevent overload
e. Report signs of dehydration promptly
Answer: A. Record all fluid intake and output b. Monitor daily weight c. Encourage oral fluid intake unless
contraindicated e. Report signs of dehydration promptly Rationale: Tracking intake/output, weight, and oral
fluid intake helps prevent worsening hypovolemia. Limiting fluids is not appropriate unless fluid overload
occurs.
Question 15: Fluids and Electrolytes A patient with hypovolemia has dry mucous membranes, poor
skin turgor, and hypotension. Which assessments indicate improvement after interventions? (Select all
that apply)
a. Urine output >30 mL/hr
b. Skin warm and pink
c. Persistent tachycardia
d. Mental status alert and oriented
e. Daily weight stable or increasing
Answer: A. Urine output >30 mL/hr b. Skin warm and pink d. Mental status alert and oriented e. Daily
weight stable or increasing Rationale: Adequate urine output, improved skin perfusion, alert mental status,
and stable weight indicate effective fluid replacement and improved perfusion. Persistent tachycardia
suggests ongoing hypovolemia.
Page 4
Answers (Grade A+)
Question 1: Fluids and Electrolytes A patient with hypervolemia presents with dyspnea, crackles in the
lungs, and jugular vein distention. Which nursing intervention is most appropriate to improve the
patient's oxygenation?
a. Encourage the patient to ambulate frequently
b. Raise the head of the bed and administer oxygen as prescribed
c. Restrict oral intake completely
d. Perform passive range-of-motion exercises
Answer: B. Raise the head of the bed and administer oxygen as prescribed Rationale: Raising the head of
the bed improves lung expansion and oxygenation. Administering oxygen supports tissue perfusion.
Ambulation and ROM are important but not immediate priorities for respiratory compromise.
Question 2: Fluids and Electrolytes Which of the following are common cardiovascular manifestations
of hypervolemia? (Select all that apply)
a. Hypotension
b. Bounding pulses
c. Tachycardia
d. Jugular vein distention
e. Bradycardia
Answer: B. Bounding pulses c. Tachycardia d. Jugular vein distention Rationale: Hypervolemia increases
blood volume, leading to bounding pulses, tachycardia, and jugular vein distention. Hypotension and
bradycardia are not typical signs of fluid overload.
Question 3: Fluids and Electrolytes A patient with hypervolemia should record their ______ at the
same time each day, as it is the most accurate indicator of fluid status.
Answer: daily weight Rationale: Daily weight measurement provides a precise assessment of fluid gain or
loss, which is critical in hypervolemia management.
Question 4: Fluids and Electrolytes You are caring for a patient with hypervolemia. Place the following
interventions in order of priority based on Maslow's hierarchy and immediate patient safety: Monitor
electrolyte levels Raise the head of the bed Administer prescribed diuretics Assess lung sounds for
crackles and dyspnea
Answer: 1. Raise the head of the bed - promotes oxygenation immediately 2. Assess lung sounds identifies
severity of fluid overload and respiratory compromise 3. Administer prescribed diuretics - reduces fluid
overload after airway is addressed 4. Monitor electrolyte levels - ensures safety during fluid removal
Rationale: Airway and breathing take priority over medications and labs in hypervolemia.
Page 1
,Question 5: Fluids and Electrolytes Which lab value should the nurse monitor closely in a patient
receiving loop diuretics for hypervolemia?
a. Sodium and potassium
b. Hemoglobin and hematocrit
c. Platelet count
d. Blood glucose
Answer: A. Sodium and potassium Rationale: Loop diuretics can cause electrolyte imbalances, especially
sodium and potassium, which can affect cardiac and neuromuscular function.
Question 6: Fluids and Electrolytes Patients with hypervolemia should limit intake of ______ to help
prevent fluid retention.
Answer: sodium Rationale: Sodium increases fluid retention by osmosis; limiting sodium helps reduce
edema and blood pressure in hypervolemia.
Question 7: Fluids and Electrolytes Which of the following are appropriate client teaching points for a
patient with hypervolemia? (Select all that apply)
a. Measure and record all fluid intake and output
b. Maintain high-sodium diet to prevent hyponatremia
c. Report rapid weight gain (>2-3 lb/day or 5 lb/week)
d. Perform strenuous exercise to reduce edema
e. Follow fluid restrictions as prescribed
Answer: A. Measure and record all fluid intake and output c. Report rapid weight gain (>2-3 lb/day or 5
lb/week) e. Follow fluid restrictions as prescribed Rationale: Monitoring I&O and weight helps detect fluid
overload early. Fluid restriction reduces excess fluid accumulation. High-sodium diet and strenuous
exercise are not appropriate interventions.
Question 8: Fluids and Electrolytes A patient with liver disease and hypervolemia has ascites, edema,
and bulging neck veins. Which assessments indicate worsening fluid overload? (Select all that apply)
a. Oxygen saturation drops from 96% to 90%
b. Crackles heard in both lung bases
c. Capillary refill < 2 seconds
d. Rapid weight gain of 4 lb in one day
e. Bounding peripheral pulses
Answer: A. Oxygen saturation drops from 96% to 90% b. Crackles heard in both lung bases d. Rapid weight
gain of 4 lb in one day e. Bounding peripheral pulses Rationale: Hypoxia (low O₂ saturation), pulmonary
crackles, rapid weight gain, and bounding pulses indicate worsening fluid overload. Normal capillary refill
(<2 seconds) does not indicate impaired perfusion.
Page 2
,Question 9: Fluids and Electrolytes A patient with hypovolemia presents with dizziness, tachycardia,
and low blood pressure. Which nursing intervention is most appropriate to improve perfusion?
a. Encourage the patient to ambulate frequently
b. Administer oral fluids only
c. Place the patient in a supine position and initiate IV fluids as prescribed
d. Restrict sodium intake
Answer: C. Place the patient in a supine position and initiate IV fluids as prescribed Rationale: Placing the
patient supine helps improve blood flow to vital organs. Administering IV fluids corrects volume deficit and
improves perfusion. Ambulation may worsen hypotension; restricting sodium does not address acute
hypovolemia.
Question 10: Fluids and Electrolytes Which of the following are common cardiovascular manifestations
of hypovolemia? (Select all that apply)
a. Hypotension, especially orthostatic
b. Bounding pulses
c. Tachycardia
d. Weak, thready pulses
e. Bradycardia
Answer: A. Hypotension, especially orthostatic c. Tachycardia d. Weak, thready pulses Rationale:
Hypovolemia decreases circulating volume, causing hypotension, tachycardia, and weak thready pulses.
Bounding pulses and bradycardia are not typical.
Question 11: Fluids and Electrolytes A patient with hypovolemia is dizzy, hypotensive, and has cool,
clammy skin. Place the following nursing actions in order of priority: Administer IV fluids as
prescribed Monitor vital signs Assess mental status and peripheral perfusion Encourage oral fluid
intake
Answer: 1. Administer IV fluids as prescribed - immediate volume replacement is critical 2. Monitor vital
signs - assess effectiveness of intervention 3. Assess mental status and peripheral perfusion - monitor
perfusion improvement 4. Encourage oral fluid intake - secondary support after stabilization Rationale:
Fluid replacement and stabilization take priority over oral intake.
Question 12: Fluids and Electrolytes Which lab values are important to monitor in a patient with
hypovolemia?
a. Electrolytes, BUN, creatinine, hematocrit
b. Blood glucose and platelets
c. Lipid profile and liver function tests
d. Coagulation panel
Answer: A. Electrolytes, BUN, creatinine, hematocrit Rationale: Hypovolemia affects renal function and
electrolyte balance. Labs help assess fluid loss severity and guide IV therapy.
Page 3
, Question 13: Fluids and Electrolytes Which of the following are early signs of dehydration in a patient
with hypovolemia?
a. Bounding pulses, edema, and shortness of breath
b. Weight gain, jugular vein distention, and crackles in lungs
c. Bradycardia, hypotension, and cool, clammy skin
d. Dizziness, dry mouth, and decreased urine output
Answer: D. Dizziness, dry mouth, and decreased urine output Rationale: Early signs of dehydration include
dizziness, dry mouth, and decreased urine output due to reduced circulating volume. Bounding pulses,
edema, and lung congestion are signs of hypervolemia. Bradycardia is not typical in hypovolemia;
hypotension and cool, clammy skin appear later in severe cases.
Question 14: Fluids and Electrolytes Which of the following are appropriate client teaching points for a
patient with hypovolemia? (Select all that apply)
a. Record all fluid intake and output
b. Monitor daily weight
c. Encourage oral fluid intake unless contraindicated
d. Limit fluid intake to prevent overload
e. Report signs of dehydration promptly
Answer: A. Record all fluid intake and output b. Monitor daily weight c. Encourage oral fluid intake unless
contraindicated e. Report signs of dehydration promptly Rationale: Tracking intake/output, weight, and oral
fluid intake helps prevent worsening hypovolemia. Limiting fluids is not appropriate unless fluid overload
occurs.
Question 15: Fluids and Electrolytes A patient with hypovolemia has dry mucous membranes, poor
skin turgor, and hypotension. Which assessments indicate improvement after interventions? (Select all
that apply)
a. Urine output >30 mL/hr
b. Skin warm and pink
c. Persistent tachycardia
d. Mental status alert and oriented
e. Daily weight stable or increasing
Answer: A. Urine output >30 mL/hr b. Skin warm and pink d. Mental status alert and oriented e. Daily
weight stable or increasing Rationale: Adequate urine output, improved skin perfusion, alert mental status,
and stable weight indicate effective fluid replacement and improved perfusion. Persistent tachycardia
suggests ongoing hypovolemia.
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