Fluid and Electrolytes NCLEX 2025 Questions and Answers
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 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.
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.
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 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 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.
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.
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.
