Exam 4: Fluid & Electrolyte Imbalances
(NCLEX)
The nurse is assessing the patient at risk for fluid volume excess. Which findings indicate that
the patient has fluid volume excess? (Select all that apply)
a. Increased, bounding pulse
b. Jugular venous distention
c. Diminished peripheral pulses
d. Presence of crackles
e. Excessive thirst
f. Elevated blood pressure
g. Orthostatic hypotension
h. Skin pale and cool to touch -
ABDFH
Which analogy best approximates the principles of diffusion and concentration gradient?
a. Game with four players on one side and eight on the other; two move over to create six per
side
b. Community fun run where 2000 participants move across the line in a mass start.
c. Basketball game of five players per side; all players move across the court.
d. Concert where 1000 people are trying to enter through a single gate. -
A
The patient's blood osmolality is 302 mOsm/L. What manifestation does the nurse expect to
see in the patient?
a. Increased urine output
b. Thirst
c. Peripheral edema
d. Nausea -
B
The patient is at risk for fluid volume excess. For self-management at home, what does the
nurse teach the patient to do?
a. Increase diuretic dose if swelling occurs.
b. Limit the amount of free water in relation to sodium intake.
c. Monitor his or her skin turgor.
d. Weigh self each day on the same scale. -
D
The older adult patient at risk for fluid and electrolyte problems is vigilantly monitored by the
nurse for the first indication of a fluid balance problem. What is this indication?
a. Fever
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,b. Mental status change
c. Poor skin turgor
d. Dry mucous membranes -
B
Which person is most likely to have symptoms related to poor lymph circulation?
a. Person with carpal tunnel syndrome
b. Marathon runner
c. Person with a history of myocardial infarction
d. Frequent overseas flyer -
D
Based on the factors of age, gender, and body type, which patient has the smallest percentage
of total body water?
a. Thin 78-year-old adult man
b. Obese 35-year-old man
c. Thin 25-year-old woman
d. Obese 68-year-old woman -
D
Which intake-output record represents the norm for the average adult?
a. 500 mL of fluid per day, ingesting an additional 200 mL of fluid from food.
b. 1500 mL of fluid per day, ingesting an additional 800 mL of fluid from food.
c. 3000 mL of fluid per day, ingesting an additional 500 mL of fluid from food.
d. 5000 mL of fluid per day, ingesting an additional 100 mL of fluid from food. -
B
What is the consequence and clinical manifestation for the patient who does not meet the
obligatory urine output?
a. Increased salivation and alkalosis
b. Increased thirst with dry mucous membranes
c. Lethal electrolyte imbalance and acidosis
d. Bradycardia and decreased nitrogen level. -
C
What is the minimum amount of urine per day needed to excrete toxic waste products?
a. 200 to 300 mL
b. 400 to 600 mL
c. 500 to 1000 mL
d. 1000 to 1500 mL -
B
Which patient in the medical surgical unit is most likely to have increased aldosterone
secretion?
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, a. Patient who has excessive salt ingestion
b. Patient who drinks a lot of water
c. Patient who loses a lot of fluid and sodium
d. Patient who loses potassium and water -
C
The patients with which conditions are at great risk for deficient fluid volume? (Select all that
apply)
a. Fever of 103 degrees F
b. Extensive burns
c. Thyroid crisis
d. Water intoxication
e. Continuous fistula drainage
f. Diabetes insipidus -
ABDEF
The nurse is working in a long-term care facility where there are numerous patients who are
immobile and at risk for dehydration. Which task is best to delegate to the unlicensed
assistive personnel (UAP)?
a. Offer patients a choice of fluids every 1 to 2 hours.
b. Check patients at the beginning of the shift to see who is thirsty.
c. Give patients extra fluids around medication times.
d. Evaluate oral intake and urinary output. -
A
The nurse is assisting a community group to plan a family sports day. In order to prevent
dehydration, what beverage does the nurse suggest be supplied?
a. Iced tea
b. Light beer
c. Diet soda
d. Bottled water -
D
The nurse is assessing the weight of the patient with chronic renal failure. The patient shows
a 2 kg weight gain since the last clinic appointment. This is equivalent to how many liters of
fluid?
a. 0.5
b. 1
c. 2
d. 3 -
C
The nurse is evaluating the hydration status of the older adult patient. If the patient is
dehydrated, the nurse expects to observe which type of cardiovascular change?
a. Hypertension with bounding peripheral pulses
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(NCLEX)
The nurse is assessing the patient at risk for fluid volume excess. Which findings indicate that
the patient has fluid volume excess? (Select all that apply)
a. Increased, bounding pulse
b. Jugular venous distention
c. Diminished peripheral pulses
d. Presence of crackles
e. Excessive thirst
f. Elevated blood pressure
g. Orthostatic hypotension
h. Skin pale and cool to touch -
ABDFH
Which analogy best approximates the principles of diffusion and concentration gradient?
a. Game with four players on one side and eight on the other; two move over to create six per
side
b. Community fun run where 2000 participants move across the line in a mass start.
c. Basketball game of five players per side; all players move across the court.
d. Concert where 1000 people are trying to enter through a single gate. -
A
The patient's blood osmolality is 302 mOsm/L. What manifestation does the nurse expect to
see in the patient?
a. Increased urine output
b. Thirst
c. Peripheral edema
d. Nausea -
B
The patient is at risk for fluid volume excess. For self-management at home, what does the
nurse teach the patient to do?
a. Increase diuretic dose if swelling occurs.
b. Limit the amount of free water in relation to sodium intake.
c. Monitor his or her skin turgor.
d. Weigh self each day on the same scale. -
D
The older adult patient at risk for fluid and electrolyte problems is vigilantly monitored by the
nurse for the first indication of a fluid balance problem. What is this indication?
a. Fever
1|Page
,b. Mental status change
c. Poor skin turgor
d. Dry mucous membranes -
B
Which person is most likely to have symptoms related to poor lymph circulation?
a. Person with carpal tunnel syndrome
b. Marathon runner
c. Person with a history of myocardial infarction
d. Frequent overseas flyer -
D
Based on the factors of age, gender, and body type, which patient has the smallest percentage
of total body water?
a. Thin 78-year-old adult man
b. Obese 35-year-old man
c. Thin 25-year-old woman
d. Obese 68-year-old woman -
D
Which intake-output record represents the norm for the average adult?
a. 500 mL of fluid per day, ingesting an additional 200 mL of fluid from food.
b. 1500 mL of fluid per day, ingesting an additional 800 mL of fluid from food.
c. 3000 mL of fluid per day, ingesting an additional 500 mL of fluid from food.
d. 5000 mL of fluid per day, ingesting an additional 100 mL of fluid from food. -
B
What is the consequence and clinical manifestation for the patient who does not meet the
obligatory urine output?
a. Increased salivation and alkalosis
b. Increased thirst with dry mucous membranes
c. Lethal electrolyte imbalance and acidosis
d. Bradycardia and decreased nitrogen level. -
C
What is the minimum amount of urine per day needed to excrete toxic waste products?
a. 200 to 300 mL
b. 400 to 600 mL
c. 500 to 1000 mL
d. 1000 to 1500 mL -
B
Which patient in the medical surgical unit is most likely to have increased aldosterone
secretion?
2|Page
, a. Patient who has excessive salt ingestion
b. Patient who drinks a lot of water
c. Patient who loses a lot of fluid and sodium
d. Patient who loses potassium and water -
C
The patients with which conditions are at great risk for deficient fluid volume? (Select all that
apply)
a. Fever of 103 degrees F
b. Extensive burns
c. Thyroid crisis
d. Water intoxication
e. Continuous fistula drainage
f. Diabetes insipidus -
ABDEF
The nurse is working in a long-term care facility where there are numerous patients who are
immobile and at risk for dehydration. Which task is best to delegate to the unlicensed
assistive personnel (UAP)?
a. Offer patients a choice of fluids every 1 to 2 hours.
b. Check patients at the beginning of the shift to see who is thirsty.
c. Give patients extra fluids around medication times.
d. Evaluate oral intake and urinary output. -
A
The nurse is assisting a community group to plan a family sports day. In order to prevent
dehydration, what beverage does the nurse suggest be supplied?
a. Iced tea
b. Light beer
c. Diet soda
d. Bottled water -
D
The nurse is assessing the weight of the patient with chronic renal failure. The patient shows
a 2 kg weight gain since the last clinic appointment. This is equivalent to how many liters of
fluid?
a. 0.5
b. 1
c. 2
d. 3 -
C
The nurse is evaluating the hydration status of the older adult patient. If the patient is
dehydrated, the nurse expects to observe which type of cardiovascular change?
a. Hypertension with bounding peripheral pulses
3|Page
