NRSG 100 Exam 4 V1 | NRSG 100
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 4) | Ivy
Tech
1. A nurse is reviewing the laboratory results of a client with a potassium level of 2.8 mEq/L.
Which clinical manifestation should the nurse prioritize?
A. Peaked T-waves
B. Hyperactive bowel sounds
C. Cardiac dysrhythmias
D. Increased muscle strength
Correct Answer: C
Hypokalemia, defined as a potassium level below 3.5 mEq/L, can cause significant cardiac
instability and life-threatening dysrhythmias. Potassium is vital for the transmission of
electrical impulses in the heart and muscles. The nurse must monitor the client’s EKG and
prepare for potassium replacement therapy as ordered.
2. A client is diagnosed with respiratory acidosis. Which of the following arterial blood gas
(ABG) results supports this diagnosis?
A. pH 7.50, HCO3 30 mEq/L
B. pH 7.48, PaCO2 30 mmHg
,C. pH 7.32, HCO3 18 mEq/L
D. pH 7.30, PaCO2 50 mmHg
Correct Answer: D
Respiratory acidosis is characterized by a pH below 7.35 and a PaCO2 above 45 mmHg.
This condition occurs when the lungs cannot adequately remove carbon dioxide, often due
to hypoventilation. The nurse should assess the client’s respiratory status and underlying
causes such as COPD or sedation.
3. A nurse is caring for a client with hypervolemia. Which assessment finding is most
consistent with fluid volume excess?
A. Flat neck veins
B. Tachycardia and hypotension
C. Distended neck veins and crackles in lungs
D. Dry mucous membranes
Correct Answer: C
Fluid volume excess leads to an increase in circulating volume, which often manifests as
jugular venous distention and pulmonary congestion. Crackles heard on auscultation
indicate fluid in the alveolar spaces. Management typically includes fluid restriction and
administration of diuretics to reduce volume.
, 4. Which intervention is most appropriate for a client who has a 24-hour urine collection
ordered?
A. Save the very first void of the 24-hour period.
B. Keep the urine at room temperature in a clear container.
C. Discard the first void and then start the clock.
D. Ask the client to skip voids if they feel too weak.
Correct Answer: C
To start a 24-hour urine collection, the first void is discarded to ensure the timing starts
with an empty bladder. All subsequent urine must be collected for exactly 24 hours and
usually kept on ice or refrigerated. If any specimen is accidentally discarded during the
period, the entire test must be restarted.
5. A nurse is assessing a client for Chvostek’s sign. A positive result indicates which electrolyte
imbalance?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypomagnesemia
Correct Answer: C
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 4) | Ivy
Tech
1. A nurse is reviewing the laboratory results of a client with a potassium level of 2.8 mEq/L.
Which clinical manifestation should the nurse prioritize?
A. Peaked T-waves
B. Hyperactive bowel sounds
C. Cardiac dysrhythmias
D. Increased muscle strength
Correct Answer: C
Hypokalemia, defined as a potassium level below 3.5 mEq/L, can cause significant cardiac
instability and life-threatening dysrhythmias. Potassium is vital for the transmission of
electrical impulses in the heart and muscles. The nurse must monitor the client’s EKG and
prepare for potassium replacement therapy as ordered.
2. A client is diagnosed with respiratory acidosis. Which of the following arterial blood gas
(ABG) results supports this diagnosis?
A. pH 7.50, HCO3 30 mEq/L
B. pH 7.48, PaCO2 30 mmHg
,C. pH 7.32, HCO3 18 mEq/L
D. pH 7.30, PaCO2 50 mmHg
Correct Answer: D
Respiratory acidosis is characterized by a pH below 7.35 and a PaCO2 above 45 mmHg.
This condition occurs when the lungs cannot adequately remove carbon dioxide, often due
to hypoventilation. The nurse should assess the client’s respiratory status and underlying
causes such as COPD or sedation.
3. A nurse is caring for a client with hypervolemia. Which assessment finding is most
consistent with fluid volume excess?
A. Flat neck veins
B. Tachycardia and hypotension
C. Distended neck veins and crackles in lungs
D. Dry mucous membranes
Correct Answer: C
Fluid volume excess leads to an increase in circulating volume, which often manifests as
jugular venous distention and pulmonary congestion. Crackles heard on auscultation
indicate fluid in the alveolar spaces. Management typically includes fluid restriction and
administration of diuretics to reduce volume.
, 4. Which intervention is most appropriate for a client who has a 24-hour urine collection
ordered?
A. Save the very first void of the 24-hour period.
B. Keep the urine at room temperature in a clear container.
C. Discard the first void and then start the clock.
D. Ask the client to skip voids if they feel too weak.
Correct Answer: C
To start a 24-hour urine collection, the first void is discarded to ensure the timing starts
with an empty bladder. All subsequent urine must be collected for exactly 24 hours and
usually kept on ice or refrigerated. If any specimen is accidentally discarded during the
period, the entire test must be restarted.
5. A nurse is assessing a client for Chvostek’s sign. A positive result indicates which electrolyte
imbalance?
A. Hyperkalemia
B. Hyponatremia
C. Hypocalcemia
D. Hypomagnesemia
Correct Answer: C
