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Fluid and Electrolytes NCLEX Questions & Answers 100% Correct &
Verified Graded A+ New Update 2025/2026
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 - 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 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
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E. Initiate cardiac monitoring. - 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 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. - A, B, C
RATIONALE:
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
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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.
E. Discourage intake of spinach.
F. Monitor for bradycardia. - A, B, D
RATIONALE:
Actions for the nurse to include when caring for a client taking a loop diuretic for heart failure include:
assessing daily weights, encouraging consumption of citrus fruits, and monitoring the client's serum
potassium. High-ceiling (loop) diuretics remove excess fluid and are potassium-depleting drugs.
Consuming citrus fruit, green leafy vegetables, cantaloupe, tomato, and other food with potassium is
indicated while receiving this type of diuretic to compensate for urinary loss of potassium.The client
must be weighed at the same time each day, using the same scale and wearing approximately the same
amount of clothes. Green leafy vegetables such as spinach contain potassium and are encouraged. The
diuretic itself has no effect on the heart rate, however potassium depletion caused by the diuretic may
cause cardiac irritability with a weak and thready pulse.
The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's
potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make?
A. Heart rate
B. Blood pressure (BP)
C. Increases in edema
3
Fluid and Electrolytes NCLEX Questions & Answers 100% Correct &
Verified Graded A+ New Update 2025/2026
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 - 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 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
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E. Initiate cardiac monitoring. - 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 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. - A, B, C
RATIONALE:
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
2
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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.
E. Discourage intake of spinach.
F. Monitor for bradycardia. - A, B, D
RATIONALE:
Actions for the nurse to include when caring for a client taking a loop diuretic for heart failure include:
assessing daily weights, encouraging consumption of citrus fruits, and monitoring the client's serum
potassium. High-ceiling (loop) diuretics remove excess fluid and are potassium-depleting drugs.
Consuming citrus fruit, green leafy vegetables, cantaloupe, tomato, and other food with potassium is
indicated while receiving this type of diuretic to compensate for urinary loss of potassium.The client
must be weighed at the same time each day, using the same scale and wearing approximately the same
amount of clothes. Green leafy vegetables such as spinach contain potassium and are encouraged. The
diuretic itself has no effect on the heart rate, however potassium depletion caused by the diuretic may
cause cardiac irritability with a weak and thready pulse.
The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's
potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make?
A. Heart rate
B. Blood pressure (BP)
C. Increases in edema
3
