NR 224: Fundamentals of Nursing - Nutrition & Fluid Balance 2026
|Chamberlain
1. Which assessment finding is a primary indicator of fluid volume deficit
(hypovolemia)?
A. Distended neck veins
B. Poor skin turgor
C. Dependent edema
D. Bounding pulse
Answer: B
Rationale: Poor skin turgor (tenting) is a classic sign of dehydration or fluid volume deficit.
Distended neck veins and edema are signs of fluid volume excess.
2. What is the most accurate method for a nurse to monitor daily fluid balance
in a hospitalized patient?
A. Measuring and recording daily weights
B. Checking skin turgor every 4 hours
C. Monitoring the patient’s blood pressure
D. Asking the patient how much they drank
Answer: A
Rationale: Daily weight at the same time, with the same scale and clothing, is the most
reliable indicator of fluid gain or loss.
,3. A patient is on a clear liquid diet. Which of the following items is permitted?
A. Vanilla pudding
B. Orange juice with pulp
C. Apple juice
D. Cream of mushroom soup
Answer: C
Rationale: Clear liquids are those that are transparent at room temperature. Apple juice is
clear, while pudding and cream soups are full liquids.
4. Which electrolyte is the primary regulator of water balance in the
extracellular fluid (ECF)?
A. Potassium
B. Calcium
C. Sodium
D. Magnesium
Answer: C
Rationale: Sodium is the most abundant cation in the ECF and plays a major role in
maintaining water balance through osmotic pressure.
5. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which
clinical manifestation should the nurse monitor for?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Cardiac dysrhythmias
D. Trousseau’s sign
Answer: C
Rationale: Hypokalemia (low potassium) can lead to life-threatening cardiac
dysrhythmias. Peaked T waves are associated with hyperkalemia.
, 6. Which vitamin is essential for blood clotting and is often given to newborns at
birth?
A. Vitamin A
B. Vitamin D
C. Vitamin C
D. Vitamin K
Answer: D
Rationale: Vitamin K is necessary for the synthesis of clotting factors. Newborns are
deficient and receive an injection to prevent bleeding.
7. A patient has a Body Mass Index (BMI) of 28. How should the nurse classify
this weight status?
A. Underweight
B. Normal weight
C. Obese
D. Overweight
Answer: D
Rationale: A BMI between 25.0 and 29.9 is classified as overweight. 18.5-24.9 is normal,
and 30+ is obese.
8. What is the recommended position for a patient receiving continuous enteral
feedings to prevent aspiration?
A. High-Fowler’s or at least 30-45 degrees
B. Supine
C. Left side-lying
D. Trendelenburg
Answer: A
Rationale: To prevent aspiration of gastric contents, the head of the bed should be
elevated at least 30 to 45 degrees during and for 30-60 minutes after feeding.
|Chamberlain
1. Which assessment finding is a primary indicator of fluid volume deficit
(hypovolemia)?
A. Distended neck veins
B. Poor skin turgor
C. Dependent edema
D. Bounding pulse
Answer: B
Rationale: Poor skin turgor (tenting) is a classic sign of dehydration or fluid volume deficit.
Distended neck veins and edema are signs of fluid volume excess.
2. What is the most accurate method for a nurse to monitor daily fluid balance
in a hospitalized patient?
A. Measuring and recording daily weights
B. Checking skin turgor every 4 hours
C. Monitoring the patient’s blood pressure
D. Asking the patient how much they drank
Answer: A
Rationale: Daily weight at the same time, with the same scale and clothing, is the most
reliable indicator of fluid gain or loss.
,3. A patient is on a clear liquid diet. Which of the following items is permitted?
A. Vanilla pudding
B. Orange juice with pulp
C. Apple juice
D. Cream of mushroom soup
Answer: C
Rationale: Clear liquids are those that are transparent at room temperature. Apple juice is
clear, while pudding and cream soups are full liquids.
4. Which electrolyte is the primary regulator of water balance in the
extracellular fluid (ECF)?
A. Potassium
B. Calcium
C. Sodium
D. Magnesium
Answer: C
Rationale: Sodium is the most abundant cation in the ECF and plays a major role in
maintaining water balance through osmotic pressure.
5. A nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which
clinical manifestation should the nurse monitor for?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Cardiac dysrhythmias
D. Trousseau’s sign
Answer: C
Rationale: Hypokalemia (low potassium) can lead to life-threatening cardiac
dysrhythmias. Peaked T waves are associated with hyperkalemia.
, 6. Which vitamin is essential for blood clotting and is often given to newborns at
birth?
A. Vitamin A
B. Vitamin D
C. Vitamin C
D. Vitamin K
Answer: D
Rationale: Vitamin K is necessary for the synthesis of clotting factors. Newborns are
deficient and receive an injection to prevent bleeding.
7. A patient has a Body Mass Index (BMI) of 28. How should the nurse classify
this weight status?
A. Underweight
B. Normal weight
C. Obese
D. Overweight
Answer: D
Rationale: A BMI between 25.0 and 29.9 is classified as overweight. 18.5-24.9 is normal,
and 30+ is obese.
8. What is the recommended position for a patient receiving continuous enteral
feedings to prevent aspiration?
A. High-Fowler’s or at least 30-45 degrees
B. Supine
C. Left side-lying
D. Trendelenburg
Answer: A
Rationale: To prevent aspiration of gastric contents, the head of the bed should be
elevated at least 30 to 45 degrees during and for 30-60 minutes after feeding.
