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FLUID AND ELECTROLYTES
NCLEX 2026 LATEST
QUESTIONS WITH 100%
VERIFIED SOLUTIONS.
The RN is assessing a 70-year-old client admitted to the unit with
severe dehydration. Which finding requires immediate
intervention by the nurse?
A. Client behavior that changes from anxious to lethargic
B. Deep furrows on the surface of the tongue
C. Poor skin turgor with tenting remaining for 2 minutes after the
skin is pinched
D. Urine output of 950 mL for the past 24 hours - ansswer -A.
Client behavior that changes from anxious to lethargic
RATIONALE:
Immediate intervention by the nurse is required when a client's
behavior changes from anxious to lethargic. This change in
mental status suggests poor cerebral blood flow and fluid shifts
within the brain cells. Immediate intervention is needed to prevent
further cerebral dysfunction.Deep furrows on the surface of the
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tongue, poor skin turgor, and low urine output are all caused by
the fluid volume deficit, but do not indicate complications of
dehydration that are immediately life-threatening.
A client with diarrhea for 3 days and inability to eat or drink well is
brought to the emergency department (ED) by her family. She
states she has been taking her diuretics for congestive heart
failure (CHF). What nursing actions are indicated at this time?
SELECT ALL THAT APPLY.
A. Place the client on bed rest.
B. Evaluate the electrolyte levels.
C. Administer the ordered diuretic.
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring. - ansswer -A, B, D, E
RATIONALE:
Nursing actions indicated at this time include: placing the client on
bedrest and assisting the client out of bed, evaluating electrolyte
levels, assessing for orthostatic hypotension, and applying a
cardiac monitor. Safety is required to prevent falls due to
weakness from a likely fluid volume deficit and electrolyte
imbalance. The nurse should review the laboratory and diagnostic
,3 | Page
results to detect likely loss of sodium, potassium, and magnesium
secondary to diarrhea and diuretic us. Fluid volume deficit is likely
with diarrhea and diuretic use and leads to fluid and electrolyte
imbalances, especially hypokalemia. Assessing for orthostatic
changes will confirm presence of volume deficit. Monitoring for
inverted T wave or presence of U wave on the ECG as well as
dysrhythmias is indicated when hypokalemia is
anticipated.Diuretics increase loss of fluids and electrolytes. The
nurse would question this order in the presence of assessment
data indicating fluid loss from the diuretics and diarrhea.
A client with hypokalemia has a prescription for parenteral
potassium chloride (KCl). Which of these interventions does the
nurse use to safely administer KCl?
SELECT ALL THAT APPLY.
A. Use a potassium infusion prepared by a registered pharmacist.
B. Assess for burning or redness during infusion.
C. Infuse at a rate of no more than 10 mEq per hour.
D. Administer only through a central venous catheter.
E. Administer by IV push only during cardiac arrest. - ansswer -A,
B, C
RATIONALE:
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Interventions to safely administer KCl to a client with hypokalemia
include: using a pharmacy prepared potassium infusion, checking
the client for any burning or redness during infusion, and infusing
the IV at not more than 10 mEq per hour. The Joint Commission's
National Client Safety Goals mandates that concentrated
potassium be diluted and added to IV solutions only in the
pharmacy by a registered pharmacist and that vials of
concentrated potassium not be available in client care areas. IV
potassium solutions irritate veins and cause phlebitis. Assess the
IV site hourly, and ask the client whether he or she feels burning
or pain at the site. The presence of pain or burning at the insertion
site may require a new intravenous to be started. A dose of KCl 5-
10 mEq/hour, no more than 20 mEq/hr is
recommended.Potassium may be administered by peripheral or
central vein. There is no circumstance where potassium is given
by IV push.
The nurse is caring for a client who is receiving a loop diuretic for
treatment of heart failure. Which of these actions will be included
in the plan of care?
SELECT ALL THAT APPLY.
A. Assess daily weights.
B. Encourage consumption of citrus fruits.
C. Weigh the client weekly.
D. Monitor serum potassium.
FLUID AND ELECTROLYTES
NCLEX 2026 LATEST
QUESTIONS WITH 100%
VERIFIED SOLUTIONS.
The RN is assessing a 70-year-old client admitted to the unit with
severe dehydration. Which finding requires immediate
intervention by the nurse?
A. Client behavior that changes from anxious to lethargic
B. Deep furrows on the surface of the tongue
C. Poor skin turgor with tenting remaining for 2 minutes after the
skin is pinched
D. Urine output of 950 mL for the past 24 hours - ansswer -A.
Client behavior that changes from anxious to lethargic
RATIONALE:
Immediate intervention by the nurse is required when a client's
behavior changes from anxious to lethargic. This change in
mental status suggests poor cerebral blood flow and fluid shifts
within the brain cells. Immediate intervention is needed to prevent
further cerebral dysfunction.Deep furrows on the surface of the
,2 | Page
tongue, poor skin turgor, and low urine output are all caused by
the fluid volume deficit, but do not indicate complications of
dehydration that are immediately life-threatening.
A client with diarrhea for 3 days and inability to eat or drink well is
brought to the emergency department (ED) by her family. She
states she has been taking her diuretics for congestive heart
failure (CHF). What nursing actions are indicated at this time?
SELECT ALL THAT APPLY.
A. Place the client on bed rest.
B. Evaluate the electrolyte levels.
C. Administer the ordered diuretic.
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring. - ansswer -A, B, D, E
RATIONALE:
Nursing actions indicated at this time include: placing the client on
bedrest and assisting the client out of bed, evaluating electrolyte
levels, assessing for orthostatic hypotension, and applying a
cardiac monitor. Safety is required to prevent falls due to
weakness from a likely fluid volume deficit and electrolyte
imbalance. The nurse should review the laboratory and diagnostic
,3 | Page
results to detect likely loss of sodium, potassium, and magnesium
secondary to diarrhea and diuretic us. Fluid volume deficit is likely
with diarrhea and diuretic use and leads to fluid and electrolyte
imbalances, especially hypokalemia. Assessing for orthostatic
changes will confirm presence of volume deficit. Monitoring for
inverted T wave or presence of U wave on the ECG as well as
dysrhythmias is indicated when hypokalemia is
anticipated.Diuretics increase loss of fluids and electrolytes. The
nurse would question this order in the presence of assessment
data indicating fluid loss from the diuretics and diarrhea.
A client with hypokalemia has a prescription for parenteral
potassium chloride (KCl). Which of these interventions does the
nurse use to safely administer KCl?
SELECT ALL THAT APPLY.
A. Use a potassium infusion prepared by a registered pharmacist.
B. Assess for burning or redness during infusion.
C. Infuse at a rate of no more than 10 mEq per hour.
D. Administer only through a central venous catheter.
E. Administer by IV push only during cardiac arrest. - ansswer -A,
B, C
RATIONALE:
, 4 | Page
Interventions to safely administer KCl to a client with hypokalemia
include: using a pharmacy prepared potassium infusion, checking
the client for any burning or redness during infusion, and infusing
the IV at not more than 10 mEq per hour. The Joint Commission's
National Client Safety Goals mandates that concentrated
potassium be diluted and added to IV solutions only in the
pharmacy by a registered pharmacist and that vials of
concentrated potassium not be available in client care areas. IV
potassium solutions irritate veins and cause phlebitis. Assess the
IV site hourly, and ask the client whether he or she feels burning
or pain at the site. The presence of pain or burning at the insertion
site may require a new intravenous to be started. A dose of KCl 5-
10 mEq/hour, no more than 20 mEq/hr is
recommended.Potassium may be administered by peripheral or
central vein. There is no circumstance where potassium is given
by IV push.
The nurse is caring for a client who is receiving a loop diuretic for
treatment of heart failure. Which of these actions will be included
in the plan of care?
SELECT ALL THAT APPLY.
A. Assess daily weights.
B. Encourage consumption of citrus fruits.
C. Weigh the client weekly.
D. Monitor serum potassium.
