NR324 EXAM 1 ACTUAL QUESTIONS & CERTIFIED
ANSWERS / 100% CORRECT
Which diagnostic tests are used to identify altered fluid balance in the body? Select all
that apply.
Complete blood count
Urine and serum osmolality
Blood culture and sensitivity
Comprehensive metabolic panel
Colonoscopy - ANSWER-Complete blood count
Urine and serum osmolality
Comprehensive metabolic panel
The nurse is caring for a client with fluid volume excess. Which medication will help the
body excrete the excess fluid?
Metoprolol
Tamsulosin
Verapamil
Furosemide - ANSWER-Furosemide
The nurse is caring for a client who presents to the emergency department with
shortness of breath. Assessment findings include crackles heard in lower lung fields,
tachycardia, hypertension, and oliguria. Which fluid imbalance is the client most likely
experiencing?
Fluid volume deficit
Renal failure
Dehydration
Fluid volume excess - ANSWER-Fluid volume excess
The nurse is caring for several clients with altered fluid balance. Which diagnostic tests
can determine if a client's condition is worsening or improving? Select all that apply.
Chest x-ray
Comprehensive metabolic panel (CMP)
Urine culture and sensitivity
Complete blood count (CBC)
Fasting blood glucose test - ANSWER-Chest x-ray
Comprehensive metabolic panel (CMP)
Complete blood count (CBC)
,The client with fluid volume deficit has been receiving 0.9% sodium chloride intravenous
(IV) infusion at 150 ml/hr for the past 4 hours. Which assessment finding indicates that
the client is developing fluid volume overload?
Poor skin turgor over the front of the chest under the collarbone
Capillary refill of the left great toe less than 3 seconds
Crackles heard with auscultation of the lower lung fields
Blood pressure 85/45 mmHg - ANSWER-Crackles heard with auscultation of the lower
lung fields
A nurse is caring for a client in the emergency department. Review the electronic health
record (EHR).
Past medical history: Heart failure, ex-smoker (15 pack years)
Past surgical history: Coronary artery bypass graft x 4 (5 years ago)
Prescribed medications:
furosemide 20 mg by mouth once daily
lisinopril 25 mg by mouth once daily
atorvastatin 25 mg by mouth once daily at bedtime
albuterol INH every 4 hours as needed for shortness of breath
aspirin 80 mg by mouth once daily
famotidine 20 mg by mouth once daily
Over-the-counter medications:
vitamin C 1000 mg by mouth once daily
Pulse: 115 beats per minute
Blood pressure: 150/89 mmHg (left arm)
Respirations: 32 breaths per minute
Oxygen saturation: 85% on room air
Temperature: 99.5 °F (37.2 °C) (oral)
The client is most likely experiencing fluid volume (deficit/excess) - ANSWER-The client
is most likely experiencing fluid volume excess
A nurse is caring for a client in the emergency department. Review the electronic health
record (EHR).
Select the information from the History & Physical and Vital Signs sections of the EHR
that indicates the client may be experiencing fluid volume excess.
Past medical history: Heart failure, ex-smoker (15 pack years)
Past surgical history: Coronary artery bypass graft x 4 (5 years ago)
Prescribed medications:
furosemide 20 mg by mouth once daily
lisinopril 25 mg by mouth once daily
,atorvastatin 25 mg by mouth once daily at bedtime
albuterol INH every 4 hours as needed for shortness of breath
aspirin 80 mg by mouth once daily
famotidine 20 mg by mouth once daily
Over-the-counter medications:
vitamin C 1000 mg by mouth once daily
Pulse: 115 beats per minute
Blood pressure: 150/89 mmHg (left arm)
Respirations: 32 breaths per minute
Oxygen saturation: 85% on room air
Temperature: 99.5 °F (oral) - ANSWER-Heart failure
Pulse
Blood pressure
Respirations
Oxygen saturation
A nurse is caring for a client in the emergency department. Review the electronic health
record (EHR).
Place the actions the nurse should complete in order, from first to last.
Introduce yourself to the client.
Assess airway, breathing, and circulation.
Elevate the head of the bed and administer oxygen 2 L per minute via nasal cannula.
Administer furosemide 40 mg intravenously as prescribed.
Monitor urine output. - ANSWER-Introduce yourself to the client.
Assess airway, breathing, and circulation.
Elevate the head of the bed and administer oxygen 2 L per minute via nasal cannula.
Administer furosemide 40 mg intravenously as prescribed.
Monitor urine output.
Which assessment findings are consistent with fluid volume deficit? Select all that apply.
Tachypnea
Orthostatic hypotension
Weight gain
Tachycardia
Dry skin and mucus membranes - ANSWER-Tachypnea
Orthostatic hypotension
Tachycardia
Dry skin and mucus membranes
Which intravenous fluid does the nurse anticipate will be administered to correct the
fluid deficit?
D5 Lactated Ringer's (LR)
, 3% NaCl
D5 0.9% NaCl
0.9% NaCl - ANSWER-0.9% NaCl
Normal saline (0.9% NaCl) is now infusing. Four hours later, the nurse reviews
laboratory findings. Which results indicate the client's condition is declining?
Blood osmolality 280 mOsm/kg
Urine specific gravity 1.025
Blood urea nitrogen 20 mg/dL
Hematocrit 55% - ANSWER-Hematocrit 55%
The nurse anticipates administering which intravenous fluids (IV) to a client with
traumatic head injury? Select all that apply.
0.225% NaCl IV fluid
0.9% NaCl IV fluid
0.45% NaCl IV fluid
D5W IV fluid
Lactated Ringers IV fluid - ANSWER-0.9% NaCl IV fluid
Lactated Ringers IV fluid
A nurse is caring for a client with renal failure who weighed 61 kilograms at admission
and now weighs 63 kilograms. How much fluid has the client
gained?
2000 mL
1000 mL
500 mL
250 mL - ANSWER-2000 mL
Select the correct answer from each dropdown menu to complete the statement.
Crystalloid solutions contain (small/large) molecules and are categorized by tonicity.
Colloid solutions contain (small/large) molecules and are called volume expanders. -
ANSWER-Crystalloid solutions contain small molecules and are categorized by tonicity.
Colloid solutions contain large molecules and are called volume expanders.
Clients with fluid volume deficit are at risk for falling. Which nursing action best
promotes safety?
Check weight daily to determine acute fluid shifts.
Reorient frequently to time, place, and situation.
Change positions slowly when rising from a bed.
Ambulate often to strengthen muscles. - ANSWER-Change positions slowly when rising
from a bed.
ANSWERS / 100% CORRECT
Which diagnostic tests are used to identify altered fluid balance in the body? Select all
that apply.
Complete blood count
Urine and serum osmolality
Blood culture and sensitivity
Comprehensive metabolic panel
Colonoscopy - ANSWER-Complete blood count
Urine and serum osmolality
Comprehensive metabolic panel
The nurse is caring for a client with fluid volume excess. Which medication will help the
body excrete the excess fluid?
Metoprolol
Tamsulosin
Verapamil
Furosemide - ANSWER-Furosemide
The nurse is caring for a client who presents to the emergency department with
shortness of breath. Assessment findings include crackles heard in lower lung fields,
tachycardia, hypertension, and oliguria. Which fluid imbalance is the client most likely
experiencing?
Fluid volume deficit
Renal failure
Dehydration
Fluid volume excess - ANSWER-Fluid volume excess
The nurse is caring for several clients with altered fluid balance. Which diagnostic tests
can determine if a client's condition is worsening or improving? Select all that apply.
Chest x-ray
Comprehensive metabolic panel (CMP)
Urine culture and sensitivity
Complete blood count (CBC)
Fasting blood glucose test - ANSWER-Chest x-ray
Comprehensive metabolic panel (CMP)
Complete blood count (CBC)
,The client with fluid volume deficit has been receiving 0.9% sodium chloride intravenous
(IV) infusion at 150 ml/hr for the past 4 hours. Which assessment finding indicates that
the client is developing fluid volume overload?
Poor skin turgor over the front of the chest under the collarbone
Capillary refill of the left great toe less than 3 seconds
Crackles heard with auscultation of the lower lung fields
Blood pressure 85/45 mmHg - ANSWER-Crackles heard with auscultation of the lower
lung fields
A nurse is caring for a client in the emergency department. Review the electronic health
record (EHR).
Past medical history: Heart failure, ex-smoker (15 pack years)
Past surgical history: Coronary artery bypass graft x 4 (5 years ago)
Prescribed medications:
furosemide 20 mg by mouth once daily
lisinopril 25 mg by mouth once daily
atorvastatin 25 mg by mouth once daily at bedtime
albuterol INH every 4 hours as needed for shortness of breath
aspirin 80 mg by mouth once daily
famotidine 20 mg by mouth once daily
Over-the-counter medications:
vitamin C 1000 mg by mouth once daily
Pulse: 115 beats per minute
Blood pressure: 150/89 mmHg (left arm)
Respirations: 32 breaths per minute
Oxygen saturation: 85% on room air
Temperature: 99.5 °F (37.2 °C) (oral)
The client is most likely experiencing fluid volume (deficit/excess) - ANSWER-The client
is most likely experiencing fluid volume excess
A nurse is caring for a client in the emergency department. Review the electronic health
record (EHR).
Select the information from the History & Physical and Vital Signs sections of the EHR
that indicates the client may be experiencing fluid volume excess.
Past medical history: Heart failure, ex-smoker (15 pack years)
Past surgical history: Coronary artery bypass graft x 4 (5 years ago)
Prescribed medications:
furosemide 20 mg by mouth once daily
lisinopril 25 mg by mouth once daily
,atorvastatin 25 mg by mouth once daily at bedtime
albuterol INH every 4 hours as needed for shortness of breath
aspirin 80 mg by mouth once daily
famotidine 20 mg by mouth once daily
Over-the-counter medications:
vitamin C 1000 mg by mouth once daily
Pulse: 115 beats per minute
Blood pressure: 150/89 mmHg (left arm)
Respirations: 32 breaths per minute
Oxygen saturation: 85% on room air
Temperature: 99.5 °F (oral) - ANSWER-Heart failure
Pulse
Blood pressure
Respirations
Oxygen saturation
A nurse is caring for a client in the emergency department. Review the electronic health
record (EHR).
Place the actions the nurse should complete in order, from first to last.
Introduce yourself to the client.
Assess airway, breathing, and circulation.
Elevate the head of the bed and administer oxygen 2 L per minute via nasal cannula.
Administer furosemide 40 mg intravenously as prescribed.
Monitor urine output. - ANSWER-Introduce yourself to the client.
Assess airway, breathing, and circulation.
Elevate the head of the bed and administer oxygen 2 L per minute via nasal cannula.
Administer furosemide 40 mg intravenously as prescribed.
Monitor urine output.
Which assessment findings are consistent with fluid volume deficit? Select all that apply.
Tachypnea
Orthostatic hypotension
Weight gain
Tachycardia
Dry skin and mucus membranes - ANSWER-Tachypnea
Orthostatic hypotension
Tachycardia
Dry skin and mucus membranes
Which intravenous fluid does the nurse anticipate will be administered to correct the
fluid deficit?
D5 Lactated Ringer's (LR)
, 3% NaCl
D5 0.9% NaCl
0.9% NaCl - ANSWER-0.9% NaCl
Normal saline (0.9% NaCl) is now infusing. Four hours later, the nurse reviews
laboratory findings. Which results indicate the client's condition is declining?
Blood osmolality 280 mOsm/kg
Urine specific gravity 1.025
Blood urea nitrogen 20 mg/dL
Hematocrit 55% - ANSWER-Hematocrit 55%
The nurse anticipates administering which intravenous fluids (IV) to a client with
traumatic head injury? Select all that apply.
0.225% NaCl IV fluid
0.9% NaCl IV fluid
0.45% NaCl IV fluid
D5W IV fluid
Lactated Ringers IV fluid - ANSWER-0.9% NaCl IV fluid
Lactated Ringers IV fluid
A nurse is caring for a client with renal failure who weighed 61 kilograms at admission
and now weighs 63 kilograms. How much fluid has the client
gained?
2000 mL
1000 mL
500 mL
250 mL - ANSWER-2000 mL
Select the correct answer from each dropdown menu to complete the statement.
Crystalloid solutions contain (small/large) molecules and are categorized by tonicity.
Colloid solutions contain (small/large) molecules and are called volume expanders. -
ANSWER-Crystalloid solutions contain small molecules and are categorized by tonicity.
Colloid solutions contain large molecules and are called volume expanders.
Clients with fluid volume deficit are at risk for falling. Which nursing action best
promotes safety?
Check weight daily to determine acute fluid shifts.
Reorient frequently to time, place, and situation.
Change positions slowly when rising from a bed.
Ambulate often to strengthen muscles. - ANSWER-Change positions slowly when rising
from a bed.
