NR324 Exam 1 QUESTIONS WITH ACTUAL CORRECT
DETAILED ANSWERS
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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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) - ANSWERS-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) - ANSWERS-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. - ANSWERS-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.
DETAILED ANSWERS
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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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) - ANSWERS-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) - ANSWERS-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. - ANSWERS-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.
