Fluid and Electrolytes NCLEX Questions,
Fluid and Electrolytes NCLEX Questions,
Chapter 13: Fluid and Electrolytes NCLEX
A client's kidneys are retaining increased amounts of sodium. The nurse plans care,
anticipating that the kidneys also are retaining greater amounts of which substances?
A. Calcium and Chloride
B. Chloride and bicarbonate
C. Potassium and Phosphates
D. Aluminum and magnesium -
Answer: B.
Rationale:
Sodium is a cation. With increased retention of sodium, the kidneys also increase
reabsorption of chloride and bicarbonate, which are anions. Options 1 and 3 are incorrect
because calcium and potassium are cations. The same is true for option 4.
A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT
irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use
to irrigate the NGT?
A. Tap water
B. Sterile Water
C. 0.9% Sodium Chloride
D. 0.45% Sodium Chloride -
Answer: C
Rationale:
Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium
chloride. Tap water, sterile water, and sodium chloride are hypotonic solutions.
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the
client's record and determines that the client was at risk for developing the potassium deficit
because of which situation?
A. Sustained tissue damage
B. Requires Nasogastric suction
C. Has a history of Addison's disease
D. Is taking a potassium-retaining diuretic -
Answer: B.
Rationale:
The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known
as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal
suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's
disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.
A nurse is assisting in the care of a client with pheochromocytoma who has been
experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the
nurse should determine that the client's status is returning to normal if which is no longer
exhibited?
1|Page
,A. Tetany
B. Tremors
C. Areflexia
D. Muscular excitability -
Answer: C
Rationale:
Signs of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of
deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany,
muscular excitability, and tremors are seen with hypomagnesemia.
During an assessment of a newly admitted client, the nurse notes that the client's heart rate is
110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his
tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little
confused and unsteady on his feet. Based on these assessment findings, the nurse suspects
that the client has which condition?
A. Dehydration
B. Hypokalemia
C. Fluid Overload
D. Hypernatremia -
Answer: A
Rationale:
When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure.
Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when
the client stands, he may experience dizziness because of insufficient blood flow to the brain.
Alterations in mental status also may occur. The oral mucous membranes, usually moist, are
dry and may be covered with a thick, pasty coating. These findings are not manifestations of
the conditions noted in the other options.
A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer
soap solution enemas until clear to a client. The UAP reports that three enemas have been
administered and that the client is still passing brown liquid stool. What should the RN
instruct the UAP to do?
A. Administer a Fleet Enema
B. Administer an oil retention enema
C. Wait 30 minutes and then administer another
enema
D. Stop administering the enemas until the health care
provider is notified -
Answer: D
Rationale:
Up to three enemas may be given when there is a prescription for enemas until clear. If more
than three are necessary, the nurse should call the HCP (or act according to agency policy).
Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect
for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and
would have no use in this situation.
The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving
intravenous (IV) fluids. Which assessment data would indicate to the nurse that the
dehydration remains unresolved?
A. An oral temperature of 98.8 F
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,B. A urine specific gravity of 1.043
C. A urine output that is pale yellow
D. A blood pressure of 120/80 mmHg -
Answer: B
Rationale:
The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal
values for urine specific gravity are 1.010 to 1.030. A temperature of 98.8° F is only 0.2 point
above the normal temperature and would not be as specific an indicator of hydration status as
would the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of
120/80 mm Hg is within normal range.
*Which client is least likely to be at risk for the development of third spacing?
A. The client with cirrhosis
B. The client with liver failure
C. The client with diabetes mellitus
D. The client with chronic kidney disease -
Answer: C
Rationale:
Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid.
Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and
pericardial sac. Third-space fluid is physiologically useless because it does not circulate to
provide nutrients for the cells. Risk factors for third spacing include clients with liver or
kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy,
gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.
A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning
care for this client, the nurse is aware that which conditions cause the release of antidiuretic
hormone (ADH)? Select all that apply.
A. Dehydration
B. HTN
C. Physiological stress
D. Decreased blood volume
E. Decreased plasma osmolarity -
Answer: A, C, and D
Rationale:
Antidiuretic hormone, or vasopressin, is produced in the brain and stored in the posterior
pituitary gland. Its release from the posterior pituitary gland is controlled by the
hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are
increased plasma osmolality, decreased blood volume, hypotension, pain, dehydration from
nausea, vomiting, or diarrhea, and stress.
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the
client is dyspneic and crackles are audible on auscultation. What additional signs would the
nurse expect to note in this client if excess fluid volume is present?
A. Weight Loss
B. Flat neck and Hand veins
C. An increase in blood pressure
D. Decreased central venous pressure (CVP) -
Answer: C
Rationale:
3|Page
, A fluid volume excess is also known as overhydration or fluid overload and occurs when
fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings
associated with fluid volume excess include cough, dyspnea, crackles, tachypnea,
tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema,
neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The
remaining options identify signs noted in fluid volume deficit.
*The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube.
Before administering an intermittent tube feeding, what should the nurse do with the 40 mL
of gastric aspirate?
A. Pour into the NG tube through a syringe with the
plunger removed
B. Dilute with water and inject into the NG tube by
putting pressure on the plunger
C. Discard properly and record as output on the
client's intake and output record.
D. Mix with the formula and pour into the NG tube
through a syringe with the plunger removed. -
Answer: A
Rationale:
After checking residual feeding contents, the gastric contents should be reinstilled to maintain
the client's electrolyte balance. The gastric contents should be poured into the NG tube
through a syringe without a plunger and not injected by pushing on the plunger. Gastric
contents are not mixed with formula or diluted with water, and should not be discarded.
A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding
should the nurse most likely expect to note in the client based on this magnesium level?
A. Tetany
B. Twitches
C. Positive Trousseau's sign
D. Loss of deep tendon reflexes -
Answer: D
Rationale:
The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5
mg/dL is experiencing hypermagnesemia. Assessment findings include neurological
depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency,
bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a
client with hypomagnesemia.
The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of
dehydration. Which assessment finding should the nurse expect to note?
A. Bradycardia
B. Elevated blood pressure
C. Changes in mental status
D. Bilateral crackles in the lung -
Answer: C
Rationale:
A client with dehydration is likely to be lethargic or complaining of a headache. The client
would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins,
tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral
4|Page
Fluid and Electrolytes NCLEX Questions,
Chapter 13: Fluid and Electrolytes NCLEX
A client's kidneys are retaining increased amounts of sodium. The nurse plans care,
anticipating that the kidneys also are retaining greater amounts of which substances?
A. Calcium and Chloride
B. Chloride and bicarbonate
C. Potassium and Phosphates
D. Aluminum and magnesium -
Answer: B.
Rationale:
Sodium is a cation. With increased retention of sodium, the kidneys also increase
reabsorption of chloride and bicarbonate, which are anions. Options 1 and 3 are incorrect
because calcium and potassium are cations. The same is true for option 4.
A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT
irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use
to irrigate the NGT?
A. Tap water
B. Sterile Water
C. 0.9% Sodium Chloride
D. 0.45% Sodium Chloride -
Answer: C
Rationale:
Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium
chloride. Tap water, sterile water, and sodium chloride are hypotonic solutions.
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the
client's record and determines that the client was at risk for developing the potassium deficit
because of which situation?
A. Sustained tissue damage
B. Requires Nasogastric suction
C. Has a history of Addison's disease
D. Is taking a potassium-retaining diuretic -
Answer: B.
Rationale:
The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known
as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal
suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's
disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.
A nurse is assisting in the care of a client with pheochromocytoma who has been
experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the
nurse should determine that the client's status is returning to normal if which is no longer
exhibited?
1|Page
,A. Tetany
B. Tremors
C. Areflexia
D. Muscular excitability -
Answer: C
Rationale:
Signs of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of
deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany,
muscular excitability, and tremors are seen with hypomagnesemia.
During an assessment of a newly admitted client, the nurse notes that the client's heart rate is
110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his
tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little
confused and unsteady on his feet. Based on these assessment findings, the nurse suspects
that the client has which condition?
A. Dehydration
B. Hypokalemia
C. Fluid Overload
D. Hypernatremia -
Answer: A
Rationale:
When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure.
Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when
the client stands, he may experience dizziness because of insufficient blood flow to the brain.
Alterations in mental status also may occur. The oral mucous membranes, usually moist, are
dry and may be covered with a thick, pasty coating. These findings are not manifestations of
the conditions noted in the other options.
A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer
soap solution enemas until clear to a client. The UAP reports that three enemas have been
administered and that the client is still passing brown liquid stool. What should the RN
instruct the UAP to do?
A. Administer a Fleet Enema
B. Administer an oil retention enema
C. Wait 30 minutes and then administer another
enema
D. Stop administering the enemas until the health care
provider is notified -
Answer: D
Rationale:
Up to three enemas may be given when there is a prescription for enemas until clear. If more
than three are necessary, the nurse should call the HCP (or act according to agency policy).
Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect
for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and
would have no use in this situation.
The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving
intravenous (IV) fluids. Which assessment data would indicate to the nurse that the
dehydration remains unresolved?
A. An oral temperature of 98.8 F
2|Page
,B. A urine specific gravity of 1.043
C. A urine output that is pale yellow
D. A blood pressure of 120/80 mmHg -
Answer: B
Rationale:
The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal
values for urine specific gravity are 1.010 to 1.030. A temperature of 98.8° F is only 0.2 point
above the normal temperature and would not be as specific an indicator of hydration status as
would the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of
120/80 mm Hg is within normal range.
*Which client is least likely to be at risk for the development of third spacing?
A. The client with cirrhosis
B. The client with liver failure
C. The client with diabetes mellitus
D. The client with chronic kidney disease -
Answer: C
Rationale:
Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid.
Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and
pericardial sac. Third-space fluid is physiologically useless because it does not circulate to
provide nutrients for the cells. Risk factors for third spacing include clients with liver or
kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy,
gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.
A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning
care for this client, the nurse is aware that which conditions cause the release of antidiuretic
hormone (ADH)? Select all that apply.
A. Dehydration
B. HTN
C. Physiological stress
D. Decreased blood volume
E. Decreased plasma osmolarity -
Answer: A, C, and D
Rationale:
Antidiuretic hormone, or vasopressin, is produced in the brain and stored in the posterior
pituitary gland. Its release from the posterior pituitary gland is controlled by the
hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are
increased plasma osmolality, decreased blood volume, hypotension, pain, dehydration from
nausea, vomiting, or diarrhea, and stress.
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the
client is dyspneic and crackles are audible on auscultation. What additional signs would the
nurse expect to note in this client if excess fluid volume is present?
A. Weight Loss
B. Flat neck and Hand veins
C. An increase in blood pressure
D. Decreased central venous pressure (CVP) -
Answer: C
Rationale:
3|Page
, A fluid volume excess is also known as overhydration or fluid overload and occurs when
fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings
associated with fluid volume excess include cough, dyspnea, crackles, tachypnea,
tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema,
neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The
remaining options identify signs noted in fluid volume deficit.
*The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube.
Before administering an intermittent tube feeding, what should the nurse do with the 40 mL
of gastric aspirate?
A. Pour into the NG tube through a syringe with the
plunger removed
B. Dilute with water and inject into the NG tube by
putting pressure on the plunger
C. Discard properly and record as output on the
client's intake and output record.
D. Mix with the formula and pour into the NG tube
through a syringe with the plunger removed. -
Answer: A
Rationale:
After checking residual feeding contents, the gastric contents should be reinstilled to maintain
the client's electrolyte balance. The gastric contents should be poured into the NG tube
through a syringe without a plunger and not injected by pushing on the plunger. Gastric
contents are not mixed with formula or diluted with water, and should not be discarded.
A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding
should the nurse most likely expect to note in the client based on this magnesium level?
A. Tetany
B. Twitches
C. Positive Trousseau's sign
D. Loss of deep tendon reflexes -
Answer: D
Rationale:
The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5
mg/dL is experiencing hypermagnesemia. Assessment findings include neurological
depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency,
bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a
client with hypomagnesemia.
The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of
dehydration. Which assessment finding should the nurse expect to note?
A. Bradycardia
B. Elevated blood pressure
C. Changes in mental status
D. Bilateral crackles in the lung -
Answer: C
Rationale:
A client with dehydration is likely to be lethargic or complaining of a headache. The client
would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins,
tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral
4|Page
