Fluid and Electrolytes NCLEX Questions
and Answers with Rationales 2025
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
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 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
D. Sodium level
A. Heart rate
RATIONALE:
The nurse must assess the heart rate for bradycardia related to digoxin and
irritability or irregularity related to hypokalemia. Hypokalemia increases the
sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even
when the digoxin level is within the therapeutic range. The nurse also assesses
for GI symptoms such as diarrhea, and other symptoms of toxicity to digoxin.The
BP may decrease with low potassium level but monitoring the pulse is essential.
The diuretic would reduce edema, therefore assessing the heart rate is the
priority. High serum sodium levels would not be expected in this scenario unless
fluid volume deficit is present.
and Answers with Rationales 2025
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
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 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
D. Sodium level
A. Heart rate
RATIONALE:
The nurse must assess the heart rate for bradycardia related to digoxin and
irritability or irregularity related to hypokalemia. Hypokalemia increases the
sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even
when the digoxin level is within the therapeutic range. The nurse also assesses
for GI symptoms such as diarrhea, and other symptoms of toxicity to digoxin.The
BP may decrease with low potassium level but monitoring the pulse is essential.
The diuretic would reduce edema, therefore assessing the heart rate is the
priority. High serum sodium levels would not be expected in this scenario unless
fluid volume deficit is present.
