NUR 101 Exam 3 Review – Health Assessment
(100% Correct | Verified Solutions) – Fortis
QUESTIONS AND ANSWERS ALREADY GRADED
A+ MATERIAL
Section 1: Fluid, Electrolyte, & Acid-Base Balance
1. A patient has a serum sodium level of 152 mEq/L (normal 135–145). Which
assessment finding would the nurse expect?
a) Muscle cramps and diarrhea
b) Thirst, dry mucous membranes, and confusion
c) Hypertension and bounding pulse
d) Weight gain and edema
Answer: b
Rationale: Sodium of 152 is hypernatremia (elevated sodium). This causes cellular
dehydration (water leaves cells) leading to thirst, dry mucous membranes,
oliguria, and neurologic changes (confusion, restlessness, seizures) . Muscle
cramps/diarrhea are seen in hyponatremia/hypokalemia. Hypertension/edema
are signs of fluid overload, not hypernatremia alone.
2. The nurse is caring for a patient with a potassium level of 2.9 mEq/L (normal
3.5–5.0). Which electrocardiogram (ECG) change would the nurse expect to see?
a) Peaked T waves
b) Prolonged PR interval and flat T waves
c) Widened QRS complex
,d) Tall, peaked P waves
Answer: b
Rationale: Hypokalemia causes flat or inverted T waves, ST depression, and
prolonged PR interval. Peaked T waves are seen in hyperkalemia. Widened QRS is
also seen in hyperkalemia.
3. The nurse is assessing a patient for signs of fluid volume deficit
(hypovolemia). Which finding is consistent with this condition?
a) Bounding pulse and hypertension
b) Jugular vein distension (JVD)
c) Orthostatic hypotension and poor skin turgor
d) Crackles in the lung bases
Answer: c
Rationale: Hypovolemia (dehydration) causes orthostatic hypotension,
tachycardia, flat neck veins, poor skin turgor, dry mucous membranes, and
decreased urine output. Bounding pulse, JVD, and crackles are signs of fluid
volume excess (hypervolemia).
4. A patient has a serum calcium level of 8.0 mg/dL (normal 8.5–10.5). The nurse
should monitor the patient for which complication?
a) Muscle spasms and positive Chvostek's sign
b) Hypertension and tachycardia
c) Constipation and lethargy
d) Polyuria and polydipsia
Answer: a
Rationale: A calcium of 8.0 is hypocalcemia. Symptoms include neuromuscular
irritability (tetany, Chvostek's and Trousseau's signs, muscle spasms,
paresthesias). Hypercalcemia causes lethargy, constipation, and polyuria.
,5. A patient has an order for IV fluids at 125 mL/hr. The IV tubing has a drop
factor of 15 gtt/mL. What is the drip rate (gtt/min)?
a) 31 gtt/min
b) 15 gtt/min
c) 125 gtt/min
d) 8 gtt/min
Answer: a
Rationale: Formula: (Volume × Drop Factor) ÷ Time in minutes = (125 mL × 15
gtt/mL) ÷ 60 min = 1875 ÷ 60 = 31.25 → 31 gtt/min.
6. A patient with heart failure is on a fluid restriction of 1500 mL/day. The
patient has received 800 mL of IV fluids and 400 mL of oral fluids so far. How
many more mL can the patient have for the remainder of the day?
a) 100 mL
b) 200 mL
c) 300 mL
d) 500 mL
Answer: c
Rationale: Total intake so far = 800 + 400 = 1200 mL. Remaining = 1500 - 1200
= 300 mL.
7. Which of the following is a nursing intervention to prevent hypokalemia in a
patient taking furosemide (Lasix), a loop diuretic?
a) Restrict dietary potassium
b) Encourage potassium-rich foods (bananas, oranges, potatoes)
c) Administer potassium-sparing diuretics instead
d) Restrict fluid intake
Answer: b
Rationale: Furosemide is a loop diuretic that causes potassium loss in the urine.
The nurse should encourage potassium-rich foods and monitor potassium levels.
, Potassium supplements may also be prescribed. Fluid restriction is not indicated
unless for heart failure.
8. The nurse is interpreting arterial blood gas (ABG) results: pH 7.32, PaCO2 52,
HCO3 24. Which condition does this indicate?
a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis
Answer: c
Rationale: pH is low (7.32) = acidosis. PaCO2 is high (52) = respiratory cause (CO2
is retained). HCO3 is normal (24). This is respiratory acidosis (e.g., COPD,
hypoventilation).
9. A patient has the following ABG results: pH 7.48, PaCO2 30, HCO3 22. The
nurse interprets this as:
a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis
Answer: b
Rationale: pH is high (7.48) = alkalosis. PaCO2 is low (30) = respiratory cause
(hyperventilation blowing off CO2). HCO3 is normal (22). This is respiratory
alkalosis.
10. A patient with diabetic ketoacidosis (DKA) has the following ABGs: pH 7.25,
PaCO2 38, HCO3 16. What is the primary acid-base imbalance?
a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
(100% Correct | Verified Solutions) – Fortis
QUESTIONS AND ANSWERS ALREADY GRADED
A+ MATERIAL
Section 1: Fluid, Electrolyte, & Acid-Base Balance
1. A patient has a serum sodium level of 152 mEq/L (normal 135–145). Which
assessment finding would the nurse expect?
a) Muscle cramps and diarrhea
b) Thirst, dry mucous membranes, and confusion
c) Hypertension and bounding pulse
d) Weight gain and edema
Answer: b
Rationale: Sodium of 152 is hypernatremia (elevated sodium). This causes cellular
dehydration (water leaves cells) leading to thirst, dry mucous membranes,
oliguria, and neurologic changes (confusion, restlessness, seizures) . Muscle
cramps/diarrhea are seen in hyponatremia/hypokalemia. Hypertension/edema
are signs of fluid overload, not hypernatremia alone.
2. The nurse is caring for a patient with a potassium level of 2.9 mEq/L (normal
3.5–5.0). Which electrocardiogram (ECG) change would the nurse expect to see?
a) Peaked T waves
b) Prolonged PR interval and flat T waves
c) Widened QRS complex
,d) Tall, peaked P waves
Answer: b
Rationale: Hypokalemia causes flat or inverted T waves, ST depression, and
prolonged PR interval. Peaked T waves are seen in hyperkalemia. Widened QRS is
also seen in hyperkalemia.
3. The nurse is assessing a patient for signs of fluid volume deficit
(hypovolemia). Which finding is consistent with this condition?
a) Bounding pulse and hypertension
b) Jugular vein distension (JVD)
c) Orthostatic hypotension and poor skin turgor
d) Crackles in the lung bases
Answer: c
Rationale: Hypovolemia (dehydration) causes orthostatic hypotension,
tachycardia, flat neck veins, poor skin turgor, dry mucous membranes, and
decreased urine output. Bounding pulse, JVD, and crackles are signs of fluid
volume excess (hypervolemia).
4. A patient has a serum calcium level of 8.0 mg/dL (normal 8.5–10.5). The nurse
should monitor the patient for which complication?
a) Muscle spasms and positive Chvostek's sign
b) Hypertension and tachycardia
c) Constipation and lethargy
d) Polyuria and polydipsia
Answer: a
Rationale: A calcium of 8.0 is hypocalcemia. Symptoms include neuromuscular
irritability (tetany, Chvostek's and Trousseau's signs, muscle spasms,
paresthesias). Hypercalcemia causes lethargy, constipation, and polyuria.
,5. A patient has an order for IV fluids at 125 mL/hr. The IV tubing has a drop
factor of 15 gtt/mL. What is the drip rate (gtt/min)?
a) 31 gtt/min
b) 15 gtt/min
c) 125 gtt/min
d) 8 gtt/min
Answer: a
Rationale: Formula: (Volume × Drop Factor) ÷ Time in minutes = (125 mL × 15
gtt/mL) ÷ 60 min = 1875 ÷ 60 = 31.25 → 31 gtt/min.
6. A patient with heart failure is on a fluid restriction of 1500 mL/day. The
patient has received 800 mL of IV fluids and 400 mL of oral fluids so far. How
many more mL can the patient have for the remainder of the day?
a) 100 mL
b) 200 mL
c) 300 mL
d) 500 mL
Answer: c
Rationale: Total intake so far = 800 + 400 = 1200 mL. Remaining = 1500 - 1200
= 300 mL.
7. Which of the following is a nursing intervention to prevent hypokalemia in a
patient taking furosemide (Lasix), a loop diuretic?
a) Restrict dietary potassium
b) Encourage potassium-rich foods (bananas, oranges, potatoes)
c) Administer potassium-sparing diuretics instead
d) Restrict fluid intake
Answer: b
Rationale: Furosemide is a loop diuretic that causes potassium loss in the urine.
The nurse should encourage potassium-rich foods and monitor potassium levels.
, Potassium supplements may also be prescribed. Fluid restriction is not indicated
unless for heart failure.
8. The nurse is interpreting arterial blood gas (ABG) results: pH 7.32, PaCO2 52,
HCO3 24. Which condition does this indicate?
a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis
Answer: c
Rationale: pH is low (7.32) = acidosis. PaCO2 is high (52) = respiratory cause (CO2
is retained). HCO3 is normal (24). This is respiratory acidosis (e.g., COPD,
hypoventilation).
9. A patient has the following ABG results: pH 7.48, PaCO2 30, HCO3 22. The
nurse interprets this as:
a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis
Answer: b
Rationale: pH is high (7.48) = alkalosis. PaCO2 is low (30) = respiratory cause
(hyperventilation blowing off CO2). HCO3 is normal (22). This is respiratory
alkalosis.
10. A patient with diabetic ketoacidosis (DKA) has the following ABGs: pH 7.25,
PaCO2 38, HCO3 16. What is the primary acid-base imbalance?
a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
