,NUR 242 Exam 2 – Medical-Surgical Nursing
– Actual Questions & Answers (GCN) 100%
Guarantee Pass
1. The nurse is monitoring fluid volume status in a client with heart failure who is at risk for
dehydration. Which intervention is the most effective for monitoring this client?
A) Monitor urine specific gravity once per shift
B) Assess skin turgor every 4 hours
C) Weigh the client every morning before breakfast
D) Measure oral intake each shift
Correct Answer: C
Rationale: Daily weight at the same time, same scale, and same clothing conditions is the most
sensitive indicator of overall fluid status. Weight changes reflect fluid shifts earlier and more
accurately than skin turgor, I&O alone, or urine specific gravity—especially in heart failure.
2. The nurse is caring for clients who have fluid overload and are at risk for complications.
Which clients are at greatest risk?
1. 22-year-old diagnosed with congenital heart failure at age 5
2. 62-year-old recently diagnosed with hepatic cirrhosis
3. 36-year-old who received hemodialysis 3 times a week for chronic kidney disease
A) Client 1 only
B) Client 2 only
C) Client 3 only
D) Clients 2 and 3
Correct Answer: D
Rationale: Cirrhosis causes hypoalbuminemia and portal hypertension, leading to third spacing,
ascites, and edema. CKD patients on hemodialysis have impaired fluid excretion and can easily
develop fluid overload. Both are at high risk.
3. Which assessment finding is consistent with fluid overload?
A) Tachycardia and thready pulse
,B) Bounding pulse and jugular venous distention
C) Decreased urine output
D) Orthostatic hypotension
Correct Answer: B
Rationale: Fluid overload presents with tachycardia, bounding pulse, hypertension, JVD, weight
gain, crackles, and pitting edema.
4. The nurse notes crackles in the lung bases, JVD, and 3+ pitting edema in a client. Which
condition should the nurse suspect?
A) Dehydration
B) Fluid volume overload
C) Electrolyte imbalance
D) Hypovolemia
Correct Answer: B
Rationale: Crackles, JVD, and pitting edema are classic signs of fluid overload (hypervolemia).
These findings indicate excess fluid in the intravascular and interstitial spaces.
5. Which lab value is expected in a client with fluid overload?
A) Increased serum osmolality
B) Decreased hemoglobin and hematocrit
C) Increased BUN
D) Urine specific gravity >1.030
Correct Answer: B
Rationale: In fluid overload, hemodilution leads to decreased hemoglobin and hematocrit.
Serum osmolality and BUN are decreased, and urine specific gravity is decreased (<1.005).
6. Which nursing intervention is appropriate for a client with fluid overload?
A) Encourage oral fluid intake
B) Restrict dietary sodium intake
C) Administer IV normal saline
D) Place in Trendelenburg position
, Correct Answer: B
Rationale: Sodium restriction helps reduce fluid retention. Diuretics may be administered. Fluid
intake should be restricted, not encouraged. IV saline would worsen the condition.
7. The nurse is assessing a client for signs of dehydration. Which finding is consistent with
dehydration?
A) Bounding pulse
B) Jugular venous distention
C) Thirst and dry mucous membranes
D) Crackles in lung bases
Correct Answer: C
Rationale: Dehydration presents with thirst, dry furrowed tongue, tachycardia, thready pulse,
hypotension, oliguria, and poor skin turgor. Bounding pulse and JVD indicate fluid overload.
8. A client has a serum osmolality of 310 mOsm/kg. This finding is consistent with:
A) Fluid overload
B) Dehydration
C) Normal fluid status
D) SIADH
Correct Answer: B
Rationale: Normal serum osmolality is 275-295 mOsm/kg. Elevated levels >295 indicate
dehydration. Decreased levels <275 indicate fluid overload or overhydration.
9. A client's urine specific gravity is 1.035. This finding suggests:
A) Fluid overload
B) Dehydration
C) Normal hydration
D) Renal failure
Correct Answer: B
Rationale: Normal urine specific gravity is 1.005-1.030. Elevated >1.030 indicates concentrated
urine, consistent with dehydration. Decreased <1.005 indicates dilute urine, consistent with
fluid overload.
– Actual Questions & Answers (GCN) 100%
Guarantee Pass
1. The nurse is monitoring fluid volume status in a client with heart failure who is at risk for
dehydration. Which intervention is the most effective for monitoring this client?
A) Monitor urine specific gravity once per shift
B) Assess skin turgor every 4 hours
C) Weigh the client every morning before breakfast
D) Measure oral intake each shift
Correct Answer: C
Rationale: Daily weight at the same time, same scale, and same clothing conditions is the most
sensitive indicator of overall fluid status. Weight changes reflect fluid shifts earlier and more
accurately than skin turgor, I&O alone, or urine specific gravity—especially in heart failure.
2. The nurse is caring for clients who have fluid overload and are at risk for complications.
Which clients are at greatest risk?
1. 22-year-old diagnosed with congenital heart failure at age 5
2. 62-year-old recently diagnosed with hepatic cirrhosis
3. 36-year-old who received hemodialysis 3 times a week for chronic kidney disease
A) Client 1 only
B) Client 2 only
C) Client 3 only
D) Clients 2 and 3
Correct Answer: D
Rationale: Cirrhosis causes hypoalbuminemia and portal hypertension, leading to third spacing,
ascites, and edema. CKD patients on hemodialysis have impaired fluid excretion and can easily
develop fluid overload. Both are at high risk.
3. Which assessment finding is consistent with fluid overload?
A) Tachycardia and thready pulse
,B) Bounding pulse and jugular venous distention
C) Decreased urine output
D) Orthostatic hypotension
Correct Answer: B
Rationale: Fluid overload presents with tachycardia, bounding pulse, hypertension, JVD, weight
gain, crackles, and pitting edema.
4. The nurse notes crackles in the lung bases, JVD, and 3+ pitting edema in a client. Which
condition should the nurse suspect?
A) Dehydration
B) Fluid volume overload
C) Electrolyte imbalance
D) Hypovolemia
Correct Answer: B
Rationale: Crackles, JVD, and pitting edema are classic signs of fluid overload (hypervolemia).
These findings indicate excess fluid in the intravascular and interstitial spaces.
5. Which lab value is expected in a client with fluid overload?
A) Increased serum osmolality
B) Decreased hemoglobin and hematocrit
C) Increased BUN
D) Urine specific gravity >1.030
Correct Answer: B
Rationale: In fluid overload, hemodilution leads to decreased hemoglobin and hematocrit.
Serum osmolality and BUN are decreased, and urine specific gravity is decreased (<1.005).
6. Which nursing intervention is appropriate for a client with fluid overload?
A) Encourage oral fluid intake
B) Restrict dietary sodium intake
C) Administer IV normal saline
D) Place in Trendelenburg position
, Correct Answer: B
Rationale: Sodium restriction helps reduce fluid retention. Diuretics may be administered. Fluid
intake should be restricted, not encouraged. IV saline would worsen the condition.
7. The nurse is assessing a client for signs of dehydration. Which finding is consistent with
dehydration?
A) Bounding pulse
B) Jugular venous distention
C) Thirst and dry mucous membranes
D) Crackles in lung bases
Correct Answer: C
Rationale: Dehydration presents with thirst, dry furrowed tongue, tachycardia, thready pulse,
hypotension, oliguria, and poor skin turgor. Bounding pulse and JVD indicate fluid overload.
8. A client has a serum osmolality of 310 mOsm/kg. This finding is consistent with:
A) Fluid overload
B) Dehydration
C) Normal fluid status
D) SIADH
Correct Answer: B
Rationale: Normal serum osmolality is 275-295 mOsm/kg. Elevated levels >295 indicate
dehydration. Decreased levels <275 indicate fluid overload or overhydration.
9. A client's urine specific gravity is 1.035. This finding suggests:
A) Fluid overload
B) Dehydration
C) Normal hydration
D) Renal failure
Correct Answer: B
Rationale: Normal urine specific gravity is 1.005-1.030. Elevated >1.030 indicates concentrated
urine, consistent with dehydration. Decreased <1.005 indicates dilute urine, consistent with
fluid overload.
