NUR160/NUR 160 Exam 4 V1 |
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a patient with a fluid volume deficit. Which clinical manifestation
should the nurse expect to find?
A. Distended neck veins
B. Crackles on lung auscultation
C. Orthostatic hypotension
D. Pitting edema in lower extremities
Correct Answer: C
Rationale: Fluid volume deficit, or hypovolemia, occurs when there is a loss of water and
electrolytes from the extracellular fluid. Orthostatic hypotension is a key sign because there
is insufficient intravascular volume to maintain blood pressure when changing positions.
Distended neck veins and crackles are associated with fluid volume excess, not deficit.
2. A patient is diagnosed with hypokalemia. Which of the following laboratory values
supports this diagnosis?
A. Potassium 3.8 mEq/L
B. Potassium 5.2 mEq/L
,C. Potassium 3.1 mEq/L
D. Potassium 4.5 mEq/L
Correct Answer: C
Rationale: The normal reference range for serum potassium is 3.5 to 5.0 mEq/L. A value of
3.1 mEq/L indicates hypokalemia, which can lead to life-threatening cardiac dysrhythmias.
The nurse must monitor the patient’s heart rhythm and provide potassium supplements as
ordered by the physician.
3. The nurse is caring for a patient receiving intravenous fluids. The nurse notes that the IV
site is cool to the touch, swollen, and the patient reports pain. What is the nurse’s priority
action?
A. Apply a warm compress to the site
B. Slow the rate of the infusion
C. Stop the infusion and remove the catheter
D. Flush the line with normal saline
Correct Answer: C
Rationale: The symptoms described, such as coolness and swelling, indicate infiltration,
where fluid leaks into the surrounding tissue. The first priority is to stop the infusion and
remove the catheter to prevent further tissue damage. After removal, the nurse should
elevate the extremity and follow facility policy for further treatment.
, 4. A patient presents with a Chvostek’s sign. Which electrolyte imbalance does the nurse
suspect?
A. Hyperkalemia
B. Hypocalcemia
C. Hyponatremia
D. Hypermagnesemia
Correct Answer: B
Rationale: Chvostek’s sign is an abnormal spasm of the facial muscles elicited by tapping
the facial nerve, indicating increased neuromuscular excitability. This is a classic
assessment finding for hypocalcemia, where calcium levels are below 8.5 mg/dL. The nurse
should also check for Trousseau’s sign and monitor the patient for seizures or tetany.
5. Which arterial blood gas (ABG) result would the nurse identify as respiratory acidosis?
A. pH 7.32, PaCO2 35 mmHg, HCO3 18 mEq/L
B. pH 7.50, PaCO2 30 mmHg, HCO3 22 mEq/L
C. pH 7.30, PaCO2 50 mmHg, HCO3 24 mEq/L
D. pH 7.48, PaCO2 40 mmHg, HCO3 30 mEq/L
Correct Answer: C
Rationale: Respiratory acidosis is characterized by a low pH (less than 7.35) and an
elevated PaCO2 (greater than 45 mmHg). Option A shows a pH of 7.30 and a CO2 of 50,
Fundamental Concepts of Practical
Nursing II Q&A with Rationale | Hondros
College of Nursing
1. A nurse is assessing a patient with a fluid volume deficit. Which clinical manifestation
should the nurse expect to find?
A. Distended neck veins
B. Crackles on lung auscultation
C. Orthostatic hypotension
D. Pitting edema in lower extremities
Correct Answer: C
Rationale: Fluid volume deficit, or hypovolemia, occurs when there is a loss of water and
electrolytes from the extracellular fluid. Orthostatic hypotension is a key sign because there
is insufficient intravascular volume to maintain blood pressure when changing positions.
Distended neck veins and crackles are associated with fluid volume excess, not deficit.
2. A patient is diagnosed with hypokalemia. Which of the following laboratory values
supports this diagnosis?
A. Potassium 3.8 mEq/L
B. Potassium 5.2 mEq/L
,C. Potassium 3.1 mEq/L
D. Potassium 4.5 mEq/L
Correct Answer: C
Rationale: The normal reference range for serum potassium is 3.5 to 5.0 mEq/L. A value of
3.1 mEq/L indicates hypokalemia, which can lead to life-threatening cardiac dysrhythmias.
The nurse must monitor the patient’s heart rhythm and provide potassium supplements as
ordered by the physician.
3. The nurse is caring for a patient receiving intravenous fluids. The nurse notes that the IV
site is cool to the touch, swollen, and the patient reports pain. What is the nurse’s priority
action?
A. Apply a warm compress to the site
B. Slow the rate of the infusion
C. Stop the infusion and remove the catheter
D. Flush the line with normal saline
Correct Answer: C
Rationale: The symptoms described, such as coolness and swelling, indicate infiltration,
where fluid leaks into the surrounding tissue. The first priority is to stop the infusion and
remove the catheter to prevent further tissue damage. After removal, the nurse should
elevate the extremity and follow facility policy for further treatment.
, 4. A patient presents with a Chvostek’s sign. Which electrolyte imbalance does the nurse
suspect?
A. Hyperkalemia
B. Hypocalcemia
C. Hyponatremia
D. Hypermagnesemia
Correct Answer: B
Rationale: Chvostek’s sign is an abnormal spasm of the facial muscles elicited by tapping
the facial nerve, indicating increased neuromuscular excitability. This is a classic
assessment finding for hypocalcemia, where calcium levels are below 8.5 mg/dL. The nurse
should also check for Trousseau’s sign and monitor the patient for seizures or tetany.
5. Which arterial blood gas (ABG) result would the nurse identify as respiratory acidosis?
A. pH 7.32, PaCO2 35 mmHg, HCO3 18 mEq/L
B. pH 7.50, PaCO2 30 mmHg, HCO3 22 mEq/L
C. pH 7.30, PaCO2 50 mmHg, HCO3 24 mEq/L
D. pH 7.48, PaCO2 40 mmHg, HCO3 30 mEq/L
Correct Answer: C
Rationale: Respiratory acidosis is characterized by a low pH (less than 7.35) and an
elevated PaCO2 (greater than 45 mmHg). Option A shows a pH of 7.30 and a CO2 of 50,
