NUR 104/NUR104 Exam 3 V2 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a patient who is experiencing fluid volume excess. Which of the
following clinical manifestations should the nurse expect to observe?
A. Distended neck veins and crackles in the lungs
B. Tachycardia and flat neck veins
C. Dry mucous membranes and decreased skin turgor
D. Increased hematocrit and BUN levels
Correct Answer: A
Expert Explanation: Fluid volume excess leads to an increase in circulating blood volume,
which typically causes distension of the jugular veins. As fluid backs up into the pulmonary
system, the nurse will often auscultate crackles in the lung bases. These findings are critical
indicators that the patient is retaining more fluid than the body can effectively manage or
excrete.
2. When administering an intramuscular (IM) injection using the Z-track method, what is the
primary purpose of this technique?
A. To seal the medication within the muscle and prevent leakage
B. To decrease the amount of pain felt by the patient
,C. To ensure the medication enters the subcutaneous tissue
D. To increase the speed of medication absorption
Correct Answer: A
Expert Explanation: The Z-track method involves pulling the skin and subcutaneous
tissue to one side before inserting the needle into the muscle. This creates a zig-zag path
that prevents the medication from leaking back out into the subcutaneous tissue after the
needle is withdrawn. It is specifically used for medications that are irritating to the tissues
or those that can cause skin staining.
3. A nurse is preparing to administer 0.5 mL of a medication subcutaneously to an adult.
Which needle size is most appropriate for this procedure?
A. 18-gauge, 1.5-inch needle
B. 22-gauge, 1-inch needle
C. 25-gauge, 5/8-inch needle
D. 20-gauge, 1-inch needle
Correct Answer: C
Expert Explanation: Subcutaneous injections require a shorter, finer needle because the
medication is delivered into the adipose tissue layer just below the dermis. A 25-gauge,
5/8-inch needle is standard for reaching this layer without penetrating the underlying
muscle. Larger needles, such as the 18-gauge, are reserved for aspiration or thick
intramuscular medications.
, 4. Which electrolyte imbalance is the most critical for the nurse to monitor in a patient taking
a loop diuretic such as Furosemide?
A. Hypernatremia
B. Hypomagnesemia
C. Hypercalcemia
D. Hypokalemia
Correct Answer: D
Expert Explanation: Loop diuretics inhibit sodium and chloride reabsorption in the loop
of Henle, which significantly increases the excretion of potassium in the urine. Low
potassium levels, or hypokalemia, can lead to life-threatening cardiac dysrhythmias and
muscle weakness. The nurse must prioritize monitoring serum potassium levels and
assessing for cardiac irregularities.
5. A patient is scheduled for elective surgery. The nurse notes that the patient has not signed
the informed consent form. What is the nurse’s primary responsibility?
A. Explain the risks and benefits of the surgery to the patient
B. Ask the patient’s next of kin to sign the form
C. Witness the patient’s signature and verify understanding
D. Notify the surgeon that the consent form has not been signed
Correct Answer: D
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a patient who is experiencing fluid volume excess. Which of the
following clinical manifestations should the nurse expect to observe?
A. Distended neck veins and crackles in the lungs
B. Tachycardia and flat neck veins
C. Dry mucous membranes and decreased skin turgor
D. Increased hematocrit and BUN levels
Correct Answer: A
Expert Explanation: Fluid volume excess leads to an increase in circulating blood volume,
which typically causes distension of the jugular veins. As fluid backs up into the pulmonary
system, the nurse will often auscultate crackles in the lung bases. These findings are critical
indicators that the patient is retaining more fluid than the body can effectively manage or
excrete.
2. When administering an intramuscular (IM) injection using the Z-track method, what is the
primary purpose of this technique?
A. To seal the medication within the muscle and prevent leakage
B. To decrease the amount of pain felt by the patient
,C. To ensure the medication enters the subcutaneous tissue
D. To increase the speed of medication absorption
Correct Answer: A
Expert Explanation: The Z-track method involves pulling the skin and subcutaneous
tissue to one side before inserting the needle into the muscle. This creates a zig-zag path
that prevents the medication from leaking back out into the subcutaneous tissue after the
needle is withdrawn. It is specifically used for medications that are irritating to the tissues
or those that can cause skin staining.
3. A nurse is preparing to administer 0.5 mL of a medication subcutaneously to an adult.
Which needle size is most appropriate for this procedure?
A. 18-gauge, 1.5-inch needle
B. 22-gauge, 1-inch needle
C. 25-gauge, 5/8-inch needle
D. 20-gauge, 1-inch needle
Correct Answer: C
Expert Explanation: Subcutaneous injections require a shorter, finer needle because the
medication is delivered into the adipose tissue layer just below the dermis. A 25-gauge,
5/8-inch needle is standard for reaching this layer without penetrating the underlying
muscle. Larger needles, such as the 18-gauge, are reserved for aspiration or thick
intramuscular medications.
, 4. Which electrolyte imbalance is the most critical for the nurse to monitor in a patient taking
a loop diuretic such as Furosemide?
A. Hypernatremia
B. Hypomagnesemia
C. Hypercalcemia
D. Hypokalemia
Correct Answer: D
Expert Explanation: Loop diuretics inhibit sodium and chloride reabsorption in the loop
of Henle, which significantly increases the excretion of potassium in the urine. Low
potassium levels, or hypokalemia, can lead to life-threatening cardiac dysrhythmias and
muscle weakness. The nurse must prioritize monitoring serum potassium levels and
assessing for cardiac irregularities.
5. A patient is scheduled for elective surgery. The nurse notes that the patient has not signed
the informed consent form. What is the nurse’s primary responsibility?
A. Explain the risks and benefits of the surgery to the patient
B. Ask the patient’s next of kin to sign the form
C. Witness the patient’s signature and verify understanding
D. Notify the surgeon that the consent form has not been signed
Correct Answer: D
