FLUID AND ELECTROLYTES NCLEX
QUESTIONS AND ANSWERS VERIFIED
RATIONALE 100% COMPLETE GRADED A+
A client develops fluid overload while in the intensive care unit. Which nursing intervention does the
nurse perform first?
A. Draws blood for laboratory tests
B. Elevates the head of the bed
C. Places the extremities in a dependent position
D. Puts the client in a side-lying position - ansB. Elevates the head of the bed
The nurse first needs to elevate the client's head of bed when caring for a client with fluid overload.
Remember to follow the ABC's and perform interventions that promote lung expansion and oxygenation
to relieve symptoms of fluid overload.Drawing blood for laboratory tests may be indicated, but would
not be performed first. Placing the extremities in a dependent position increases peripheral edema, and
positioning the client in a side-
A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider
orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which
of these best practice techniques does the nurse include when administering this medication?
SELECT ALL THAT APPLY.
A. Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution
B. Use a vein in the hand for better flow
C. Use an IV pump to deliver the medication
D. Check IV access for blood return after the infusion
E. Push the medication over 5 minutes - ansA, C
RATIONALE:
Best practice technique for administering IV potassium replacement is to ensure that the concentration
is no greater than 1 mEq/10 mL of solution. A pump or controller device must be used to deliver the
medication to prevent rapid infusion and complications of hyperkalemia, including cardiac
arrest.Potassium must be infused via a large vein with a high volume of flow, avoiding the hand. The
, FLUID AND ELECTROLYTES NCLEX
QUESTIONS AND ANSWERS VERIFIED
RATIONALE 100% COMPLETE GRADED A+
maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20
mEq/hr. Potassium would never be administered via IV push. Assess the IV access for placement and an
adequate blood return before administering potassium-containing solutions.
A client is brought to the emergency department for increasing weakness and muscle twitching. The
laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the
nurse make?
SELECT ALL THAT APPLY.
A. History of liver disease
B. Use of salt substitute
C. Use of an ACE inhibitor
D. Potassium-sparing diuretics
E. Prescription for insulin - ansB, C, D,
RATIONALE:
When caring for an ED client with an elevated potassium level, the nurse needs to assess the client for
any use of salt substitutes, any use of ACE inhibitors or potassium-sparing diuretics, as well as kidney
disease.History of liver disease does not increase the client's potassium level. Insulin, which moves
potassium into the cell, can be used as a treatment for hyperkalemia, in addition to diabetes. Taking
insulin would lower the potassium level.
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.
, FLUID AND ELECTROLYTES NCLEX
QUESTIONS AND ANSWERS VERIFIED
RATIONALE 100% COMPLETE GRADED A+
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring. - ansA, 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 hypermagnesemia is seen in the emergency department (ED). Which of these interventions
is most appropriate?
A. Monitor for hyperactive reflexes
B. prepare for endotracheal intubation
C. Institute teaching on avoiding magnesium rich foods
D. Place the client on a cardiac monitor - ansD. Place the client on a cardiac monitor
RATIONALE:
Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore
instituting cardiac monitoring is most appropriate.Reflexes are typically reduced in the presence of
hypermagnesemia. There is no indication that the client has signs and symptoms of respiratory distress
at this time, however the nurse would monitor the client for respiratory weakness and respiratory
failure. The nurse will institute teaching after the emergency passes and the cause of the magnesium
excess is determined.
QUESTIONS AND ANSWERS VERIFIED
RATIONALE 100% COMPLETE GRADED A+
A client develops fluid overload while in the intensive care unit. Which nursing intervention does the
nurse perform first?
A. Draws blood for laboratory tests
B. Elevates the head of the bed
C. Places the extremities in a dependent position
D. Puts the client in a side-lying position - ansB. Elevates the head of the bed
The nurse first needs to elevate the client's head of bed when caring for a client with fluid overload.
Remember to follow the ABC's and perform interventions that promote lung expansion and oxygenation
to relieve symptoms of fluid overload.Drawing blood for laboratory tests may be indicated, but would
not be performed first. Placing the extremities in a dependent position increases peripheral edema, and
positioning the client in a side-
A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider
orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which
of these best practice techniques does the nurse include when administering this medication?
SELECT ALL THAT APPLY.
A. Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution
B. Use a vein in the hand for better flow
C. Use an IV pump to deliver the medication
D. Check IV access for blood return after the infusion
E. Push the medication over 5 minutes - ansA, C
RATIONALE:
Best practice technique for administering IV potassium replacement is to ensure that the concentration
is no greater than 1 mEq/10 mL of solution. A pump or controller device must be used to deliver the
medication to prevent rapid infusion and complications of hyperkalemia, including cardiac
arrest.Potassium must be infused via a large vein with a high volume of flow, avoiding the hand. The
, FLUID AND ELECTROLYTES NCLEX
QUESTIONS AND ANSWERS VERIFIED
RATIONALE 100% COMPLETE GRADED A+
maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20
mEq/hr. Potassium would never be administered via IV push. Assess the IV access for placement and an
adequate blood return before administering potassium-containing solutions.
A client is brought to the emergency department for increasing weakness and muscle twitching. The
laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the
nurse make?
SELECT ALL THAT APPLY.
A. History of liver disease
B. Use of salt substitute
C. Use of an ACE inhibitor
D. Potassium-sparing diuretics
E. Prescription for insulin - ansB, C, D,
RATIONALE:
When caring for an ED client with an elevated potassium level, the nurse needs to assess the client for
any use of salt substitutes, any use of ACE inhibitors or potassium-sparing diuretics, as well as kidney
disease.History of liver disease does not increase the client's potassium level. Insulin, which moves
potassium into the cell, can be used as a treatment for hyperkalemia, in addition to diabetes. Taking
insulin would lower the potassium level.
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.
, FLUID AND ELECTROLYTES NCLEX
QUESTIONS AND ANSWERS VERIFIED
RATIONALE 100% COMPLETE GRADED A+
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring. - ansA, 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 hypermagnesemia is seen in the emergency department (ED). Which of these interventions
is most appropriate?
A. Monitor for hyperactive reflexes
B. prepare for endotracheal intubation
C. Institute teaching on avoiding magnesium rich foods
D. Place the client on a cardiac monitor - ansD. Place the client on a cardiac monitor
RATIONALE:
Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore
instituting cardiac monitoring is most appropriate.Reflexes are typically reduced in the presence of
hypermagnesemia. There is no indication that the client has signs and symptoms of respiratory distress
at this time, however the nurse would monitor the client for respiratory weakness and respiratory
failure. The nurse will institute teaching after the emergency passes and the cause of the magnesium
excess is determined.
