Nur 170 Final Exam Questions And
Answers Rated A+ New Update Assured
Satisfaction
SECTION A: Fluid & Electrolyte Balance (Questions 1-30)
1. A nurse is assessing a client who has a serum sodium level of 128 mEq/L. Which
finding should the nurse expect?
A) Hyperreflexia and muscle twitching
B) Thirst and dry mucous membranes
C) Confusion and muscle weakness
D) Oliguria and edema
Answer: C) Confusion and muscle weakness
Rationale: Hyponatremia (serum sodium < 135 mEq/L) causes water movement into
brain cells, leading to cerebral edema. Early manifestations include confusion, headache,
and muscle weakness. Hyperreflexia is seen in hypocalcemia or hypermagnesemia. Thirst
indicates hypernatremia. Oliguria is associated with fluid volume deficit, not isolated
hyponatremia.
2. A client with heart failure has a serum potassium of 5.8 mEq/L. Which
intervention should the nurse implement first?
,A) Administer potassium supplements as ordered
B) Restrict dietary potassium intake
C) Notify the healthcare provider immediately
D) Encourage increased fluid intake
Answer: C) Notify the healthcare provider immediately
Rationale: Hyperkalemia (> 5.0 mEq/L) is a life-threatening emergency that can cause
cardiac arrhythmias. The nurse should notify the provider immediately while monitoring
cardiac rhythm. Potassium supplements are contraindicated. Dietary restriction is
important but not the priority action.
3. A client is receiving IV fluids at 150 mL/hour. The nurse assesses crackles in the
lung bases and jugular vein distention. The nurse should identify that the client is
experiencing:
A) Hypovolemia
B) Fluid volume excess
C) Hypertonic dehydration
D) Third-spacing of fluid
Answer: B) Fluid volume excess
Rationale: Crackles, jugular vein distention, and increased IV fluid rate are classic signs
of fluid volume excess (hypervolemia). This occurs when fluid intake exceeds output or
when fluid shifts into the vascular space. Hypovolemia presents with hypotension,
tachycardia, and flat neck veins.
,4. Which client is at highest risk for developing hypomagnesemia?
A) A client with chronic kidney disease
B) A client with a history of alcohol use disorder
C) A client receiving magnesium-containing antacids
D) A client with hypoparathyroidism
Answer: B) A client with history of alcohol use disorder
Rationale: Chronic alcohol use leads to poor nutrition, decreased gastrointestinal
absorption, and increased renal excretion of magnesium. Chronic kidney disease and
magnesium-containing antacids increase the risk of hypermagnesemia.
Hypoparathyroidism is associated with hyperphosphatemia and hypocalcemia.
5. The nurse is reviewing laboratory results for a client with severe vomiting.
Which acid-base imbalance should the nurse expect?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: B) Metabolic alkalosis
Rationale: Severe vomiting causes loss of hydrochloric acid (HCl) from the stomach,
leading to metabolic alkalosis (increased pH and HCO3⁻). This is a common cause of
metabolic alkalosis. Metabolic acidosis occurs with diarrhea or renal failure. Respiratory
imbalances relate to lung function and CO2 retention or loss.
, 6. A client with chronic obstructive pulmonary disease (COPD) has an arterial
blood gas (ABG) showing: pH 7.31, PaCO2 58 mm Hg, HCO3 30 mEq/L. The nurse
should interpret this as:
A) Metabolic acidosis, uncompensated
B) Respiratory acidosis, partially compensated
C) Respiratory alkalosis, uncompensated
D) Metabolic alkalosis, fully compensated
Answer: B) Respiratory acidosis, partially compensated
Rationale: pH is low (acidosis), PaCO2 is elevated (respiratory cause), and HCO3 is
elevated (metabolic compensation). Compensation is partial because pH remains
abnormal. In fully compensated states, pH returns to normal range (7.35-7.45). COPD
clients retain CO2, making them prone to respiratory acidosis.
7. The nurse is caring for a client with a calcium level of 7.8 mg/dL. Which
assessment finding is most consistent with this laboratory value?
A) Positive Chvostek's sign
B) Bone pain and pathologic fractures
C) Flaccid paralysis
D) Polyuria and polydipsia
Answer: A) Positive Chvostek's sign
Rationale: Hypocalcemia (serum calcium < 8.5 mg/dL) causes neuromuscular irritability
manifested by positive Chvostek's sign (facial twitching when tapping the facial nerve)
and Trousseau's sign (carpal spasm with blood pressure cuff inflation). Bone pain and
fractures are associated with hypercalcemia. Flaccid paralysis is seen in severe
hyperkalemia.
Answers Rated A+ New Update Assured
Satisfaction
SECTION A: Fluid & Electrolyte Balance (Questions 1-30)
1. A nurse is assessing a client who has a serum sodium level of 128 mEq/L. Which
finding should the nurse expect?
A) Hyperreflexia and muscle twitching
B) Thirst and dry mucous membranes
C) Confusion and muscle weakness
D) Oliguria and edema
Answer: C) Confusion and muscle weakness
Rationale: Hyponatremia (serum sodium < 135 mEq/L) causes water movement into
brain cells, leading to cerebral edema. Early manifestations include confusion, headache,
and muscle weakness. Hyperreflexia is seen in hypocalcemia or hypermagnesemia. Thirst
indicates hypernatremia. Oliguria is associated with fluid volume deficit, not isolated
hyponatremia.
2. A client with heart failure has a serum potassium of 5.8 mEq/L. Which
intervention should the nurse implement first?
,A) Administer potassium supplements as ordered
B) Restrict dietary potassium intake
C) Notify the healthcare provider immediately
D) Encourage increased fluid intake
Answer: C) Notify the healthcare provider immediately
Rationale: Hyperkalemia (> 5.0 mEq/L) is a life-threatening emergency that can cause
cardiac arrhythmias. The nurse should notify the provider immediately while monitoring
cardiac rhythm. Potassium supplements are contraindicated. Dietary restriction is
important but not the priority action.
3. A client is receiving IV fluids at 150 mL/hour. The nurse assesses crackles in the
lung bases and jugular vein distention. The nurse should identify that the client is
experiencing:
A) Hypovolemia
B) Fluid volume excess
C) Hypertonic dehydration
D) Third-spacing of fluid
Answer: B) Fluid volume excess
Rationale: Crackles, jugular vein distention, and increased IV fluid rate are classic signs
of fluid volume excess (hypervolemia). This occurs when fluid intake exceeds output or
when fluid shifts into the vascular space. Hypovolemia presents with hypotension,
tachycardia, and flat neck veins.
,4. Which client is at highest risk for developing hypomagnesemia?
A) A client with chronic kidney disease
B) A client with a history of alcohol use disorder
C) A client receiving magnesium-containing antacids
D) A client with hypoparathyroidism
Answer: B) A client with history of alcohol use disorder
Rationale: Chronic alcohol use leads to poor nutrition, decreased gastrointestinal
absorption, and increased renal excretion of magnesium. Chronic kidney disease and
magnesium-containing antacids increase the risk of hypermagnesemia.
Hypoparathyroidism is associated with hyperphosphatemia and hypocalcemia.
5. The nurse is reviewing laboratory results for a client with severe vomiting.
Which acid-base imbalance should the nurse expect?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
Answer: B) Metabolic alkalosis
Rationale: Severe vomiting causes loss of hydrochloric acid (HCl) from the stomach,
leading to metabolic alkalosis (increased pH and HCO3⁻). This is a common cause of
metabolic alkalosis. Metabolic acidosis occurs with diarrhea or renal failure. Respiratory
imbalances relate to lung function and CO2 retention or loss.
, 6. A client with chronic obstructive pulmonary disease (COPD) has an arterial
blood gas (ABG) showing: pH 7.31, PaCO2 58 mm Hg, HCO3 30 mEq/L. The nurse
should interpret this as:
A) Metabolic acidosis, uncompensated
B) Respiratory acidosis, partially compensated
C) Respiratory alkalosis, uncompensated
D) Metabolic alkalosis, fully compensated
Answer: B) Respiratory acidosis, partially compensated
Rationale: pH is low (acidosis), PaCO2 is elevated (respiratory cause), and HCO3 is
elevated (metabolic compensation). Compensation is partial because pH remains
abnormal. In fully compensated states, pH returns to normal range (7.35-7.45). COPD
clients retain CO2, making them prone to respiratory acidosis.
7. The nurse is caring for a client with a calcium level of 7.8 mg/dL. Which
assessment finding is most consistent with this laboratory value?
A) Positive Chvostek's sign
B) Bone pain and pathologic fractures
C) Flaccid paralysis
D) Polyuria and polydipsia
Answer: A) Positive Chvostek's sign
Rationale: Hypocalcemia (serum calcium < 8.5 mg/dL) causes neuromuscular irritability
manifested by positive Chvostek's sign (facial twitching when tapping the facial nerve)
and Trousseau's sign (carpal spasm with blood pressure cuff inflation). Bone pain and
fractures are associated with hypercalcemia. Flaccid paralysis is seen in severe
hyperkalemia.
