ATI Exam #1 (Med Surg.) QUESTIONS
WITH CORRECT ANSWERS
A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon
assessment, the client
has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min,
respirations 24/min, skin
cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated
with a high specific
gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select
all that apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea - Answer-A. CORRECT: Decreased skin turgor is a clinical manifestation
present with fluid volume deficit. Skin
turgor is decreased to due to the lack of fluid within the body and results in dryness of
the skin.
B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume
deficit. The
urine is concentrated due to urinary output being decreased.
D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume
deficit. Low-grade fever
is one of the body's ways to maintain homeostasis to compensate for lack of fluid within
the body.
E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit.
Increased
respirations are the body's way to obtain oxygen due to the lack of fluid volume within
the body.
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and
weight gain
of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client
has a temperature
37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L
oxygen via nasal
cannula, and blood pressure 152/96 mm Hg. Which of the following clinical
manifestations are indicative
of fluid volume excess? (Select all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
D. Hypertension
, E. Weakness - Answer-A. CORRECT: Dyspnea is a clinical manifestation present with
fluid volume excess. Dyspnea is due to
an excess of fluids within the body and lungs, and the client is struggling to breath to
obtain oxygen.
B. CORRECT: Edema is a clinical manifestation present with fluid volume excess.
Edema is due to the
excess of fluid within the body. Weight gain can be a result of edema.
D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess.
Blood pressure
rises as the heart must work harder due to the excess fluid.
E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess.
Weakness is due
to the excess fluid that is retained, which depletes energy and increases the workload
for the body.
A nurse is caring for a client who is dehydrated. Which of the following clinical
manifestations should
the nurse assess for that is indicative of fluid volume deficit?
A. Moist skin
B. Distended neck veins
C. Increased urinary output
D. Tachycardia - Answer-D. CORRECT: Tachycardia is an attempt to maintain blood
pressure, a clinical manifestation
indicative of fluid volume deficit.
A nurse is caring for an older adult client in a long-term care facility. The client has
become weak and
confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's
temperature is 38.3° C
(100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg.
He has lost ¾ lb
and reports dizziness when assisted to the bathroom. He also has a nonproductive
cough with diminished
breath sounds in the right lower lobe. Which of the following actions should the nurse
take?
A. Initiate fluid restrictions to limit intake.
B. Observe for signs of hypertension.
C. Encourage the client to ambulate to promote oxygenation.
D. Monitor respirations for shortness of breath. - Answer-D. CORRECT: It is an
appropriate action for the nurse to monitor the client's respiratory status and for
shortness of breath. The client has a nonproductive cough with diminished breath
sounds in the
right lower lobe. This client is dehydrated and has fluid volume deficit.
A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and
K+ 3.4 mEq/L.
WITH CORRECT ANSWERS
A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon
assessment, the client
has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min,
respirations 24/min, skin
cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated
with a high specific
gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select
all that apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea - Answer-A. CORRECT: Decreased skin turgor is a clinical manifestation
present with fluid volume deficit. Skin
turgor is decreased to due to the lack of fluid within the body and results in dryness of
the skin.
B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume
deficit. The
urine is concentrated due to urinary output being decreased.
D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume
deficit. Low-grade fever
is one of the body's ways to maintain homeostasis to compensate for lack of fluid within
the body.
E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit.
Increased
respirations are the body's way to obtain oxygen due to the lack of fluid volume within
the body.
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and
weight gain
of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client
has a temperature
37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L
oxygen via nasal
cannula, and blood pressure 152/96 mm Hg. Which of the following clinical
manifestations are indicative
of fluid volume excess? (Select all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
D. Hypertension
, E. Weakness - Answer-A. CORRECT: Dyspnea is a clinical manifestation present with
fluid volume excess. Dyspnea is due to
an excess of fluids within the body and lungs, and the client is struggling to breath to
obtain oxygen.
B. CORRECT: Edema is a clinical manifestation present with fluid volume excess.
Edema is due to the
excess of fluid within the body. Weight gain can be a result of edema.
D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess.
Blood pressure
rises as the heart must work harder due to the excess fluid.
E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess.
Weakness is due
to the excess fluid that is retained, which depletes energy and increases the workload
for the body.
A nurse is caring for a client who is dehydrated. Which of the following clinical
manifestations should
the nurse assess for that is indicative of fluid volume deficit?
A. Moist skin
B. Distended neck veins
C. Increased urinary output
D. Tachycardia - Answer-D. CORRECT: Tachycardia is an attempt to maintain blood
pressure, a clinical manifestation
indicative of fluid volume deficit.
A nurse is caring for an older adult client in a long-term care facility. The client has
become weak and
confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's
temperature is 38.3° C
(100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg.
He has lost ¾ lb
and reports dizziness when assisted to the bathroom. He also has a nonproductive
cough with diminished
breath sounds in the right lower lobe. Which of the following actions should the nurse
take?
A. Initiate fluid restrictions to limit intake.
B. Observe for signs of hypertension.
C. Encourage the client to ambulate to promote oxygenation.
D. Monitor respirations for shortness of breath. - Answer-D. CORRECT: It is an
appropriate action for the nurse to monitor the client's respiratory status and for
shortness of breath. The client has a nonproductive cough with diminished breath
sounds in the
right lower lobe. This client is dehydrated and has fluid volume deficit.
A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and
K+ 3.4 mEq/L.
