NUR 113 exam 1 exam with complete
SOLUTIONS
A patient has dehydration. While planning care, the nurse considers that the majority of
the patient's total water volume exists in with compartment?
a. intracellular
b. extracellular
c. intravascular
d. transcellular - ANSa. intracellular
rationale: Intracellular (inside the cells) fluid accounts for approximately two thirds of
total body water. Extracellular (outside the cells) is approximately one third of the total
body water. Intravascular fluid (liquid portion of the blood) and transcellular fluid are two
major divisions of the extracellular compartment.
The nurse is teaching about the process of passively moving water from an area of
lower particle concentration to an area of higher particle concentration. Which process
is the nurse describing?
a. Osmosis
b. Filtration
c. Diffusion
d. Active transport - ANSa. osmosis
rationale: The process of moving water from an area of low particle concentration to an
area of higher particle concentration is known as osmosis. Filtration is mediated by fluid
pressure from an area of higher pressure to an area of lower pressure. Diffusion is
passive movement of electrolytes or other particles down the concentration gradient
(from areas of higher concentration to areas of lower concentration). Active transport
requires energy in the form of adenosine triphosphate (ATP) to move electrolytes
across cell membranes against the concentration gradient (from areas of lower
concentration to areas of higher concentration).efg
The nurse observes edema in a patient who has venous congestion from right heart
failure. Which type of pressure facilitated the formation of the patient's edema?
a. osmotic
b. oncotic
c. hydrostatic
d. concentration - ANSc. hydrostatic
,rationale: Venous congestion increases capillary hydrostatic pressure. Increased
hydrostatic pressure causes edema by causing increased movement of fluid into the
interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes
and can contribute to edema in other situations, such as inflammation or malnutrition.
Concentration pressure is not a nursing term.
The nurse administers an intravenous (IV) hypertonic solution to a patient. In which
direction will the fluid shift?
a. From intracellular to extracellular
b. From extracellular to intracellular
c. From intravascular to intracellular
d. From intravascular to interstitial - ANSa. from intracellular to extracellular
rationale: Hypertonic solutions will move fluid from the intracellular to the extracellular
(intravascular). A hypertonic solution has a concentration greater than normal body
fluids, so water will shift out of cells because of the osmotic pull of the extra particles.
Movement of water from the extracellular (intravascular) into cells (intracellular) occurs
when hypotonic fluids are administered. Distribution of fluid between intravascular and
interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.
A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the
nurse perform the steps starting with the first one?
1. Clean site.
2. Select vein.
3. Apply tourniquet.
4. Release tourniquet.
5. Reapply tourniquet.
6. Advance and secure.
7. Insert vascular access device. - ANS3, 2, 4, 1, 5, 7, 6
rationale: The steps for inserting an intravenous catheter are as follows: Apply
tourniquet; select vein; release tourniquet; clean site; reapply tourniquet; insert vascular
access device; and advance and secure.
The nurse is reviewing laboratory results. Which cation will the nurse observe is the
most abundant in the blood?
a. Sodium
b. Chloride
c. Potassium
d. Magnesium - ANSa. sodium
rationale: Sodium is the most abundant cation in the blood. Potassium is the
predominant intracellular cation. Chloride is an anion (negatively charged) rather than a
cation (positively charged). Magnesium is found predominantly inside cells and in bone.
,The nurse receives the patient's most recent blood work results. Which laboratory value
is of greatest concern?
a. Sodium of 145 mEq/L
b. Calcium of 15.5 mg/dL
c. Potassium of 3.5 mEq/L
d. Chloride of 100 mEq/L - ANSb. calcium of 15.5 mg/dL
rationale: Normal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is
abnormally high and of concern. The rest of the laboratory values are within their normal
ranges: sodium 136 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106
mEq/L.
The nurse observes that the patient's calcium is elevated. When checking the
phosphate level, what does the nurse expect to see?
a. Increased
b. Decreased
c. Equal to calcium
d. No change in phosphate - ANSb. decreased
rationale: Phosphate will decrease. Serum calcium and phosphate have an inverse
relationship. When one is elevated, the other decreases, except in some patients with
end-stage renal disease.
Four patients arrive at the emergency department at the same time. Which patient will
the nurse see first?
a. An infant with temperature of 102.2° F and diarrhea for 3 days
b. A teenager with a sprained ankle and excessive edema
c. A middle-aged adult with abdominal pain who is moaning and holding her stomach
d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60 -
ANSa. an infant with temperature of 102.2° F and diarrhea for 3 days
rationale: The infant should be seen first. An infant's proportion of total body water (70%
to 80% total body weight) is greater than that of children or adults. Infants and young
children have greater water needs and immature kidneys. They are at greater risk for
extracellular volume deficit and hypernatremia because body water loss is
proportionately greater per kilogram of weight. A teenager with excessive edema from a
sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older
adult with a blood pressure of 112/60.
The patient has an intravenous (IV) line and the nurse needs to remove the gown. In
which order will the nurse perform the steps, starting with the first one?
1. Remove the sleeve of the gown from the arm without the IV.
2. Remove the sleeve of the gown from the arm with the IV.
3. Remove the IV solution container from its stand.
4. Pass the IV bag and tubing through the sleeve. - ANS1, 2, 3, 4
, rationale: Change regular gowns by following these steps for maximum speed and arm
mobility: (1) To remove a gown, remove the sleeve of the gown from the arm without the
IV line, maintaining the patient's privacy. (2) Remove the sleeve of the gown from the
arm with the IV line. (3) Remove the IV solution container from its stand, and pass it and
the tubing through the sleeve. (If this involves removing the tubing from an EID, use the
roller clamp to slow the infusion to prevent the accidental infusion of a large volume of
solution or medication.)
A 2-year-old child is brought into the emergency department after ingesting a
medication that causes respiratory depression. For which acid-base imbalance will the
nurse most closely monitor this child?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis - ANSb. respiratory acidosis
rationale: Respiratory depression leads to hypoventilation. Hypoventilation results in
retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from
hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance
would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that
affect metabolic acids.
A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low
intermittent suction for the past 3 days. Which arterial blood gas values will the nurse
expect to observe?
a. Respiratory alkalosis
b. Metabolic alkalosis
c. Metabolic acidosis
d. Respiratory acidosis - ANSb. metabolic alkalosis
rationale: The patient is losing acid from the nasogastric tube so the patient will have
metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis.
Metabolic acidosis will occur when too much acid is in the body like kidney failure.
Which blood gas result will the nurse expect to observe in a patient with respiratory
alkalosis?
a. pH 7.60, PaCO2 40 mm Hg, HCO3 - 30 mEq/L
b. pH 7.53, PaCO2 30 mm Hg, HCO3 - 24 mEq/L
c. pH 7.35, PaCO2 35 mm Hg, HCO3 - 26 mEq/L
d. pH 7.25, PaCO2 48 mm Hg, HCO3 - 23 mEq/L - ANSb. pH 7.53, PaCO2 30 mmHg,
HCO3- 24 mEq/L
rationale: Respiratory alkalosis should show an alkalotic pH and decreased CO2
(respiratory) values, with a normal HCO3 - . In this case, pH 7.53 is alkaline (normal =
7.35 to 7.45), PaCO2 is 30 (normal 35 to 45 mm Hg), and HCO3 - is 24 (normal = 22 to
26 mEq/L). A result of pH 7.60, PaCO2 40 mm Hg, HCO3 - 30 mEq/L is metabolic
SOLUTIONS
A patient has dehydration. While planning care, the nurse considers that the majority of
the patient's total water volume exists in with compartment?
a. intracellular
b. extracellular
c. intravascular
d. transcellular - ANSa. intracellular
rationale: Intracellular (inside the cells) fluid accounts for approximately two thirds of
total body water. Extracellular (outside the cells) is approximately one third of the total
body water. Intravascular fluid (liquid portion of the blood) and transcellular fluid are two
major divisions of the extracellular compartment.
The nurse is teaching about the process of passively moving water from an area of
lower particle concentration to an area of higher particle concentration. Which process
is the nurse describing?
a. Osmosis
b. Filtration
c. Diffusion
d. Active transport - ANSa. osmosis
rationale: The process of moving water from an area of low particle concentration to an
area of higher particle concentration is known as osmosis. Filtration is mediated by fluid
pressure from an area of higher pressure to an area of lower pressure. Diffusion is
passive movement of electrolytes or other particles down the concentration gradient
(from areas of higher concentration to areas of lower concentration). Active transport
requires energy in the form of adenosine triphosphate (ATP) to move electrolytes
across cell membranes against the concentration gradient (from areas of lower
concentration to areas of higher concentration).efg
The nurse observes edema in a patient who has venous congestion from right heart
failure. Which type of pressure facilitated the formation of the patient's edema?
a. osmotic
b. oncotic
c. hydrostatic
d. concentration - ANSc. hydrostatic
,rationale: Venous congestion increases capillary hydrostatic pressure. Increased
hydrostatic pressure causes edema by causing increased movement of fluid into the
interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes
and can contribute to edema in other situations, such as inflammation or malnutrition.
Concentration pressure is not a nursing term.
The nurse administers an intravenous (IV) hypertonic solution to a patient. In which
direction will the fluid shift?
a. From intracellular to extracellular
b. From extracellular to intracellular
c. From intravascular to intracellular
d. From intravascular to interstitial - ANSa. from intracellular to extracellular
rationale: Hypertonic solutions will move fluid from the intracellular to the extracellular
(intravascular). A hypertonic solution has a concentration greater than normal body
fluids, so water will shift out of cells because of the osmotic pull of the extra particles.
Movement of water from the extracellular (intravascular) into cells (intracellular) occurs
when hypotonic fluids are administered. Distribution of fluid between intravascular and
interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.
A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the
nurse perform the steps starting with the first one?
1. Clean site.
2. Select vein.
3. Apply tourniquet.
4. Release tourniquet.
5. Reapply tourniquet.
6. Advance and secure.
7. Insert vascular access device. - ANS3, 2, 4, 1, 5, 7, 6
rationale: The steps for inserting an intravenous catheter are as follows: Apply
tourniquet; select vein; release tourniquet; clean site; reapply tourniquet; insert vascular
access device; and advance and secure.
The nurse is reviewing laboratory results. Which cation will the nurse observe is the
most abundant in the blood?
a. Sodium
b. Chloride
c. Potassium
d. Magnesium - ANSa. sodium
rationale: Sodium is the most abundant cation in the blood. Potassium is the
predominant intracellular cation. Chloride is an anion (negatively charged) rather than a
cation (positively charged). Magnesium is found predominantly inside cells and in bone.
,The nurse receives the patient's most recent blood work results. Which laboratory value
is of greatest concern?
a. Sodium of 145 mEq/L
b. Calcium of 15.5 mg/dL
c. Potassium of 3.5 mEq/L
d. Chloride of 100 mEq/L - ANSb. calcium of 15.5 mg/dL
rationale: Normal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is
abnormally high and of concern. The rest of the laboratory values are within their normal
ranges: sodium 136 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106
mEq/L.
The nurse observes that the patient's calcium is elevated. When checking the
phosphate level, what does the nurse expect to see?
a. Increased
b. Decreased
c. Equal to calcium
d. No change in phosphate - ANSb. decreased
rationale: Phosphate will decrease. Serum calcium and phosphate have an inverse
relationship. When one is elevated, the other decreases, except in some patients with
end-stage renal disease.
Four patients arrive at the emergency department at the same time. Which patient will
the nurse see first?
a. An infant with temperature of 102.2° F and diarrhea for 3 days
b. A teenager with a sprained ankle and excessive edema
c. A middle-aged adult with abdominal pain who is moaning and holding her stomach
d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60 -
ANSa. an infant with temperature of 102.2° F and diarrhea for 3 days
rationale: The infant should be seen first. An infant's proportion of total body water (70%
to 80% total body weight) is greater than that of children or adults. Infants and young
children have greater water needs and immature kidneys. They are at greater risk for
extracellular volume deficit and hypernatremia because body water loss is
proportionately greater per kilogram of weight. A teenager with excessive edema from a
sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older
adult with a blood pressure of 112/60.
The patient has an intravenous (IV) line and the nurse needs to remove the gown. In
which order will the nurse perform the steps, starting with the first one?
1. Remove the sleeve of the gown from the arm without the IV.
2. Remove the sleeve of the gown from the arm with the IV.
3. Remove the IV solution container from its stand.
4. Pass the IV bag and tubing through the sleeve. - ANS1, 2, 3, 4
, rationale: Change regular gowns by following these steps for maximum speed and arm
mobility: (1) To remove a gown, remove the sleeve of the gown from the arm without the
IV line, maintaining the patient's privacy. (2) Remove the sleeve of the gown from the
arm with the IV line. (3) Remove the IV solution container from its stand, and pass it and
the tubing through the sleeve. (If this involves removing the tubing from an EID, use the
roller clamp to slow the infusion to prevent the accidental infusion of a large volume of
solution or medication.)
A 2-year-old child is brought into the emergency department after ingesting a
medication that causes respiratory depression. For which acid-base imbalance will the
nurse most closely monitor this child?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis - ANSb. respiratory acidosis
rationale: Respiratory depression leads to hypoventilation. Hypoventilation results in
retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from
hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance
would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that
affect metabolic acids.
A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low
intermittent suction for the past 3 days. Which arterial blood gas values will the nurse
expect to observe?
a. Respiratory alkalosis
b. Metabolic alkalosis
c. Metabolic acidosis
d. Respiratory acidosis - ANSb. metabolic alkalosis
rationale: The patient is losing acid from the nasogastric tube so the patient will have
metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis.
Metabolic acidosis will occur when too much acid is in the body like kidney failure.
Which blood gas result will the nurse expect to observe in a patient with respiratory
alkalosis?
a. pH 7.60, PaCO2 40 mm Hg, HCO3 - 30 mEq/L
b. pH 7.53, PaCO2 30 mm Hg, HCO3 - 24 mEq/L
c. pH 7.35, PaCO2 35 mm Hg, HCO3 - 26 mEq/L
d. pH 7.25, PaCO2 48 mm Hg, HCO3 - 23 mEq/L - ANSb. pH 7.53, PaCO2 30 mmHg,
HCO3- 24 mEq/L
rationale: Respiratory alkalosis should show an alkalotic pH and decreased CO2
(respiratory) values, with a normal HCO3 - . In this case, pH 7.53 is alkaline (normal =
7.35 to 7.45), PaCO2 is 30 (normal 35 to 45 mm Hg), and HCO3 - is 24 (normal = 22 to
26 mEq/L). A result of pH 7.60, PaCO2 40 mm Hg, HCO3 - 30 mEq/L is metabolic
