Bald Nathan
A nurse is assessing a patient with fluid volume overload. Which findings should the nurse expect? (Select all that apply.)
A. Distended neck veins
B. Weak, thready pulse
C. Pitting edema
D. Moist crackles in lungs
Correct Answers: A, C, D
Rationale: Fluid volume overload increases venous return and causes edema, crackles, and bounding pulses—not weak ones
Which patients are most at risk for developing dehydration? (Select all that apply.)
A. Patients with fever
B. Patients with diarrhea
C. Patients on diuretics
D. Patients receiving blood transfusions
Correct Answers: A, B, C
Rationale: Fever, diarrhea, and diuretics increase fluid loss. Blood transfusions replace fluids
Which complications are associated with fluid volume overload? (Select all that apply.)
A. Pulmonary edema
B. Increased blood pressure
C. Weight gain
D. Hypothermia
Correct Answers: A, B, C
Rationale: Fluid retention increases pressure, causes crackles, and weight gain
Which lab result reflects a normal calcium (Ca²⁺) level?
A. 7.0–8.0 mg/dL
B. 8.5–10.5 mg/dL
C. 1.3–2.1 mEq/L
D. 135–145 mEq/L
Correct Answer: B
Rationale: Normal calcium levels range from 8.5–10.5 mg/dL, vital for bone strength, clotting, and muscle contraction
Which electrolyte imbalance is most associated with peaked T waves on ECG?
A. Hypokalemia
B. Hyperkalemia
C. Hypocalcemia
D. Hyponatremia
Correct Answer: B
Rationale: Elevated potassium increases cardiac excitability, causing peaked T waves
A patient with calcium level 7.6 mg/dL is at risk for which manifestation?
A. Muscle twitching and positive Trousseau’s sign
B. Decreased reflexes
C. Lethargy and confusion
D. Constipation
Correct Answer: A
Rationale: Hypocalcemia increases neuromuscular excitability, producing tetany and positive Trousseau’s sign
Which finding at an IV site is most indicative of infiltration?
A. Warmth and redness along the vein
B. Swelling and coolness around the insertion site
C. Burning and vein hardness
D. Purulent drainage from the catheter
Correct Answer: B
Rationale: Infiltration occurs when IV fluid leaks into surrounding tissue, causing swelling, coolness, and discomfort
A nurse is caring for a patient with dehydration. Which assessment findings support this diagnosis? (Select all that apply.)
A. Flat neck veins
B. Weak, rapid pulse
C. Moist mucous membranes
D. Poor skin turgor
Correct Answers: A, B, D
Rationale: Dehydration causes decreased vascular volume, leading to weak pulses, flat veins, and dry, tented skin
Which ECG change is expected with hyperkalemia?
A. Flattened T waves
B. Peaked T waves
C. ST depression
D. U waves
Correct Answer: B
Rationale: Hyperkalemia increases cardiac excitability, producing peaked, tall T waves on ECG
Which nursing interventions are appropriate for dehydration management? (Select all that apply.)
A. Encourage oral fluids
B. Monitor urine output
C. Administer diuretics
D. Assess daily weight
Correct Answers: A, B, D
Rationale: Rehydration includes fluid replacement, intake/output, and weight monitoring. Diuretics worsen fluid loss
A patient with heart failure is ordered Normal Saline (0.9% NaCl). What should the nurse do?
A. Administer as prescribed
B. Question the order
C. Increase infusion rate
D. Administer a diuretic first
Correct Answer: B
Rationale: NS increases extracellular fluid and can worsen heart failure by causing overload
Which assessment finding requires immediate intervention in a patient receiving IV fluids?
A. Crackles in lung bases
B. Dry lips
C. Mild tachycardia
D. Slightly elevated temperature
Correct Answer: A
Rationale: Crackles indicate pulmonary edema, requiring prompt fluid adjustment
A patient’s sodium level is 128 mEq/L. Which finding should the nurse expect?
A. Dry, flushed skin
B. Muscle weakness and confusion
C. Bounding pulses
D. Thirst and restlessness
Correct Answer: B
Rationale: Hyponatremia causes neurologic symptoms such as confusion and muscle weakness due to cellular swelling
Which of the following findings is characteristic of phlebitis?
A. Cool, pale skin at IV site
B. Redness, warmth, and a palpable cord along the vein
C. Decreased capillary refill
D. Bleeding from the insertion site
Correct Answer: B
Rationale: Phlebitis is vein inflammation, causing redness, warmth, pain, and a palpable vein pathway
Which magnesium (Mg²⁺) value is considered normal?
A. 1.3–2.1 mEq/L
B. 3.5–5.0 mEq/L
C. 8.5–10.5 mg/dL
D. 136–145 mEq/L
Correct Answer: A
Rationale: Normal serum magnesium is 1.3–2.1 mEq/L and is important for neuromuscular and cardiac stability
Which signs would indicate hypocalcemia? (Select all that apply.)
A. Positive Trousseau’s sign
B. Positive Chvostek’s sign
C. Paresthesia
D. Bradycardia
Correct Answers: A, B, C
Rationale: Neuromuscular irritability causes Trousseau’s and Chvostek’s signs, tingling, and muscle twitching
A patient has been prescribed D5 0.45% NS after initial NS therapy for DKA. Which actions are appropriate? (Select all that apply.)
A. Monitor for signs of hypoglycemia
B. Monitor for cerebral edema
C. Continue solution if glucose is < 250 mg/dL
D. Evaluate serum osmolality
Correct Answers: A, B, D
Rationale: D5 0.45% NS prevents hypoglycemia and rapid osmotic shifts; stop if glucose <250
A patient receiving IV D5W begins to show signs of confusion and headache. What is the priority action?
A. Slow the infusion
B. Stop the IV immediately
C. Assess blood glucose
D. Notify provider
Correct Answer: A
Rationale: D5W becomes hypotonic after dextrose metabolism, which can cause cerebral swelling; slowing rate prevents overload
Which solution is contraindicated in patients with renal failure?
A. Lactated Ringer’s
B. 0.9% Normal Saline
C. D5W
D. Normosol-R
Correct Answer: A
Rationale: LR contains potassium, which can worsen hyperkalemia in renal failure
Which assessment finding is most associated with hypernatremia?
A. Hypotension
B. Lethargy and dry mucous membranes
C. Muscle twitching and decreased thirst
D. Weight loss with edema
Correct Answer: B
Rationale: Hypernatremia causes dehydration of cells, leading to thirst, dry mucous membranes, and lethargy
A nurse suspects thrombosis at an IV site. Which action should the nurse take first?
A. Flush the line with saline
B. Remove the IV and apply a cold compress
C. Massage the area to improve flow
D. Elevate the limb above heart level
Correct Answer: B
Rationale: Thrombosis (clot formation) requires immediate removal and cold application to reduce inflammation; never flush or massage
The nurse should monitor for which complications when giving hypotonic IV fluids? (Select all that apply.)
A. Cerebral edema
B. Seizures
C. Increased intracranial pressure
D. Hypernatremia
Correct Answers: A, B, C
Rationale: Hypotonic fluids move water into cells, risking cerebral edema, seizures, and ICP elevation—not hypernatremia
A nurse is teaching about sodium imbalance. Which statements show correct understanding? (Select all that apply.)
A. Sodium helps regulate fluid balance
B. Sodium is the major intracellular electrolyte
C. Hyponatremia can cause confusion and weakness
D. Hypernatremia can lead to thirst and dry mucous membranes
Correct Answers: A, C, D
Rationale: Sodium controls extracellular volume; potassium dominates intracellular space
Which value is within the normal range for serum potassium (K⁺)?
A. 2.0–3.5 mEq/L
B. 3.5–5.0 mEq/L
C. 8.5–10.5 mg/dL
D. 1.3–2.1 mEq/L
Correct Answer: B
Rationale: Normal potassium is 3.5–5.0 mEq/L and is the main intracellular cation responsible for muscle and cardiac function
Which finding in a patient with dehydration indicates the treatment has been effective?
A. Flat neck veins
B. Urine output 50 mL/hr
C. Weight loss of 3 lbs
D. Dry mucous membranes
Correct Answer: B
Rationale: Output ≥30 mL/hr and moist membranes show effective rehydration
Which finding requires further teaching for a patient with an implanted port?
A. “It’s accessed with a non-coring needle.”
B. “I should flush it monthly between uses.”
C. “I can use any needle to access it.”
D. “It’s placed under the skin in my chest.”
Correct Answer: C
Rationale: Only non-coring needles should be used; others damage the port septum
Which finding is expected in hypercalcemia?
A. Muscle cramps and tetany
B. Bone pain and lethargy
C. Seizures
D. Paresthesia
Correct Answer: B
Rationale: Hypercalcemia decreases neuromuscular activity, causing weakness, bone pain, and confusion
Which statement about a midline catheter requires further teaching?
A. “I can use it for vesicant drugs like chemotherapy.”
B. “It can stay in place up to 14 days.”
C. “It is inserted in the antecubital vein.”
D. “It should not be used for parenteral nutrition solutions.”
Correct Answer: A
Rationale: Midlines must not be used for vesicant or high-osmolality fluids because of tissue damage risk
Which manifestations are associated with fluid volume deficit? (Select all that apply.)
A. Decreased BP
B. Increased heart rate
C. Dry mucous membranes
D. Distended neck veins
Correct Answers: A, B, C
Rationale: Low volume triggers tachycardia, hypotension, and dehydration signs; distended neck veins are seen in overload
Which findings require immediate nursing intervention for a patient with IV therapy? (Select all that apply.)
A. Redness and warmth along the vein
B. Swelling and coolness at the site
C. Patient reports burning sensation
D. Transparent dressing intact with no swelling
Correct Answers: A, B, C
Rationale: Signs of infiltration or phlebitis need discontinuation of IV and site change
Which symptoms suggest infiltration of an IV line? (Select all that apply.)
A. Swelling and coolness at insertion site
B. Pain or discomfort
C. Pale skin at site
D. Warm, red area following vein path
Correct Answers: A, B, C
Rationale: Infiltration causes leakage, cool swelling, and pallor; warmth and redness indicate phlebitis
A nurse notices a patient's IV site is red, warm, and painful along the vein. Which complication is suspected?
A. Infiltration
B. Phlebitis
C. Thrombosis
D. Air embolism
Correct Answer: B
Rationale: Redness and warmth along the vein are classic signs of phlebitis
Which intervention should the nurse implement for a patient with a PICC line?
A. Encourage heavy lifting for arm strength
B. Flush the line only when needed
C. Avoid blood draws from any lumen
D. Avoid excessive physical activity
Correct Answer: D
Rationale: Excessive movement may dislodge or damage the catheter
A patient with magnesium level of 1.0 mEq/L may experience which signs?
A. Hypoactive deep tendon reflexes
B. Hyperactive reflexes and tremors
C. Decreased respirations
D. Bradycardia
Correct Answer: B
Rationale: Hypomagnesemia increases neuromuscular excitability, causing tremors and hyperreflexia
Which statement about a Peripherally Inserted Central Catheter (PICC) indicates proper understanding?
A. “I can still lift weights as long as it doesn’t hurt.”
B. “It can be used for blood draws.”
C. “It is inserted into the subclavian vein.”
D. “It can only stay in for a few days.”
Correct Answer: B
Rationale: PICCs may be used for blood draws if the lumen is large enough (4 Fr or greater)
Which action is most appropriate for a patient with intraosseous infusion therapy?
A. Use for up to 48 hours
B. Insert into a fractured bone
C. Monitor for compartment syndrome
D. Use for mild dehydration only
Correct Answer: C
Rationale: IO access risks tissue compression; monitor for compartment syndrome
Which finding indicates possible hyponatremia?
A. Increased thirst and dry tongue
B. Confusion and muscle weakness
C. Bounding pulses and crackles
D. Tachycardia and hypertension
Correct Answer: B
Rationale: Low sodium causes neurological and muscular symptoms
Which of the following would require immediate action by the nurse?
A. Patient with dry mucous membranes
B. Patient with weak pulses
C. Patient with crackles and shortness of breath
D. Patient with urine output 600 mL/24hr
Correct Answer: C
Rationale: Pulmonary congestion and dyspnea indicate fluid overload and potential respiratory distress
Which statement indicates a patient needs further teaching about IV therapy?
A. “If my IV site hurts, I should tell my nurse.”
B. “A little swelling near my IV site is normal.”
C. “The nurse checks my IV site regularly.”
D. “I should not move my arm excessively.”
Correct Answer: B
Rationale: Any swelling may indicate infiltration or phlebitis and should be reported
The nurse is monitoring a patient on D5 0.9% NS. Which finding is most concerning?
A. Crackles in lungs
B. Heart rate 88 bpm
C. Mild thirst
D. BP 118/76 mmHg
Correct Answer: A
Rationale: D5NS is hypertonic and can cause fluid overload leading to pulmonary edema
Which assessment finding is consistent with hypermagnesemia?
A. Tetany and seizures
B. Muscle weakness and diminished reflexes
C. Increased deep tendon reflexes
D. Restlessness and irritability
Correct Answer: B
Rationale: Excess magnesium depresses the CNS, causing weakness, bradycardia, and decreased reflexes
A patient has a central venous catheter with an antibiotic cuff. Which type of line does this describe?
A. Nontunneled percutaneous catheter
B. Tunneled central venous catheter
C. PICC line
D. Implanted port
Correct Answer: B
Rationale: Tunneled catheters (e.g., Hickman, Broviac) have antibiotic cuffs to prevent infection during long-term use
Which IV fluids are considered isotonic? (Select all that apply.)
A. 0.9% Normal Saline (NS)
B. D5W (before metabolism)
C. 0.45% Normal Saline
D. Lactated Ringer’s (LR)
Correct Answers: A, B, D
Rationale: NS, D5W, and LR are isotonic solutions; 0.45% NS is hypotonic
A patient with a potassium level of 2.8 mEq/L would most likely exhibit which finding?
A. Bradycardia
B. Hypoactive bowel sounds and muscle weakness
C. Increased reflexes and agitation
D. Hypertension
Correct Answer: B
Rationale: Hypokalemia causes decreased muscle and GI activity, leading to weakness and constipation
Which findings indicate improvement in a patient treated for dehydration? (Select all that apply.)
A. Urine output > 500 mL/day
B. Moist mucous membranes
C. Flat neck veins
D. Stable pulse rate
Correct Answers: A, B, D
Rationale: Adequate hydration restores urine output, moist membranes, and stable vital signs
Which fluid is best to replace lost fluids in a burn patient?
A. D5W
B. 0.45% NS
C. Lactated Ringer’s
D. D5 0.9% NS
Correct Answer: C
Rationale: LR replaces electrolytes and buffers pH, appropriate for burns
Which of the following represents the normal range for serum sodium (Na⁺)?
A. 125–135 mEq/L
B. 136–145 mEq/L
C. 3.5–5.0 mEq/L
D. 1.6–2.6 mg/dL
Correct Answer: B
Rationale: Normal serum sodium is 136–145 mEq/L; it maintains extracellular fluid balance and nerve impulse transmission
To test for Trousseau’s sign, the nurse should:
A. Tap the facial nerve and observe twitching
B. Inflate a blood pressure cuff and observe for carpal spasm
C. Ask the patient to extend the tongue and watch for tremor
D. Check for eye twitching when light is shined
Correct Answer: B
Rationale: Trousseau’s sign is elicited by inflating a BP cuff and observing carpal spasm—an indicator of hypocalcemia
What is the minimum amount of urine output needed daily to excrete metabolic waste?
A. 200–300 mL/day
B. 400–600 mL/day
C. 800–1000 mL/day
D. 1500–2000 mL/day
Correct Answer: B
Rationale: At least 400–600 mL/day of urine is needed to eliminate toxins; lower amounts indicate renal perfusion problems
Which hormone promotes sodium and water retention while excreting potassium?
A. Antidiuretic hormone (ADH)
B. Atrial natriuretic peptide (ANP)
C. Aldosterone
D. Renin
Correct Answer: C
Rationale: Aldosterone, secreted by the adrenal cortex, increases sodium and water reabsorption and promotes potassium excretion
Which process involves water moving across a semipermeable membrane from an area of low solute concentration to high solute concentration?
A. Diffusion
B. Active transport
C. Osmosis
D. Filtration
Correct Answer: C
Rationale: Osmosis is the passive movement of water to equalize solute concentration on both sides of a membrane
Which statement about Chvostek’s sign indicates correct understanding by the nursing student?
A. “It’s a facial muscle twitch when the facial nerve is tapped.”
B. “It’s caused by low potassium levels.”
C. “It’s a sign of magnesium excess.”
D. “It occurs when BP cuff inflation causes hand spasm.”
Correct Answer: A
Rationale: Chvostek’s sign is positive when tapping the facial nerve triggers facial twitching, seen in hypocalcemia and hypomagnesemia
Which component of the Renin-Angiotensin-Aldosterone System (RAAS) causes vasoconstriction and stimulates aldosterone release?
A. Angiotensin I
B. Angiotensin II
C. Renin
D. ACE enzyme
Correct Answer: B
Rationale: Angiotensin II constricts vessels, increases blood pressure, and stimulates the adrenal glands to release aldosterone
A patient has an increased osmolality level. What does this indicate?
A. Overhydration
B. Low solute concentration
C. Hemodilution
D. Dehydration
Correct Answer: D
Rationale: High osmolality means the blood is more concentrated with solutes, commonly seen in dehydration
Which statement by a nursing student about Antidiuretic Hormone (ADH) indicates a need for further teaching?
A. “ADH promotes water reabsorption in the kidneys.”
B. “ADH is produced in the hypothalamus but stored in the posterior pituitary.”
C. “ADH causes diuresis by increasing urine output.”
D. “ADH helps regulate plasma osmolality.”
Correct Answer: C
Rationale: ADH reduces diuresis by promoting water reabsorption. Saying it “causes diuresis” is incorrect
Which factor can significantly increase insensible water loss?
A. Mild exercise
B. High-protein diet
C. Fever or severe burns
D. Hypothermia
Correct Answer: C
Rationale: Fever, trauma, burns, and hypermetabolic states increase insensible water loss through skin and lungs