2
NCLEX Fluid and Electrolytes || || || ||
Questions With Answers || || ||
What is the nurse's primary concern regarding fluid & electrolytes when
|| || || || || || || || || || ||
caring for an elderly pt who is intermittently confused?
|| || || || || || || ||
1. risk of dehydration
|| || ||
2. risk of kidney damage
|| || || ||
3. risk of stroke
|| || ||
4. risk of bleeding - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || || ||
Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a
|| || || || || || || || || || || || || ||
pt with an altered level of consciousness, there is an increased risk of
|| || || || || || || || || || || || ||
dehydration & high serum osmolality. || || || ||
Rationale 2: The risks for kidney damage are not specifically related to aging
|| || || || || || || || || || || || ||
or fluid & electrolyte issues.
|| || || ||
Rationale 3: The risk of stroke is not specifically related to aging or fluid &
|| || || || || || || || || || || || || || ||
electrolyte issues. ||
Rationale 4: The risk of bleeding is not specifically related to aging or fluid &
|| || || || || || || || || || || || || || ||
electrolyte issues. ||
The nurse is planning care for a pt with severe burns. Which of the following
|| || || || || || || || || || || || || || ||
is this pt at risk for developing?
|| || || || || ||
1. intracellular fluid deficit
|| || ||
2. intracellular fluid overload
|| || ||
, 2
3. extracellular fluid deficit
|| || ||
4. interstitial fluid deficit - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || || ||
Rationale 1: Because this pt was severely burned, the fluid within the cells is
|| || || || || || || || || || || || || ||
diminished, leading to an intracellular fluid deficit.|| || || || || ||
Rationale 2: The intracellular fluid is all fluids that exist within the cell
|| || || || || || || || || || || || ||
cytoplasm & nucleus. Because this pt was severely burned, the fluid within
|| || || || || || || || || || || ||
the cells is diminished, leading to an intracellular fluid deficit.
|| || || || || || || || ||
Rationale 3: The extracellular fluid is all fluids that exist outside the cell,
|| || || || || || || || || || || || ||
including the interstitial fluid between the cells. Because this pt was severely
|| || || || || || || || || || || ||
burned, the fluid within the cells is diminished, leading to an intracellular
|| || || || || || || || || || || ||
fluid deficit.
||
Rationale 4: The extracellular fluid is all fluids that exist outside the cell,
|| || || || || || || || || || || || ||
including the interstitial fluid between the cells. Because this pt was severely
|| || || || || || || || || || || ||
burned, the fluid within the cells is diminished, leading to an intracellular
|| || || || || || || || || || || ||
fluid deficit.
||
A pt, experiencing multisystem fluid volume deficit, has the symptoms of
|| || || || || || || || || || ||
tachycardia, pale, cool skin, & decreased urine output. The nurse realizes
|| || || || || || || || || || ||
these findings are most likely a direct result of which of the following?
|| || || || || || || || || || || ||
1. the body's natural compensatory mechanisms
|| || || || ||
2. pharmacological effects of a diuretic
|| || || || ||
3. effects of rapidly infused intravenous fluids
|| || || || || ||
4. cardiac failure - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || ||
, 2
Rationale 1: The internal vasoconstrictive compensatory reactions within the
|| || || || || || || || ||
body are responsible for the symptoms exhibited. The body naturally attempts
|| || || || || || || || || ||
to conserve fluid internally specifically for the brain & heart.
|| || || || || || || || || ||
Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
|| || || || || || || || || || ||
Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in
|| || || || || || || || || || || ||
urine output. ||
Rationale 4: The manifestations reported are not indicative of cardiac failure
|| || || || || || || || || || ||
in this pt.
|| ||
A pregnant pt is admitted with excessive thirst, increased urination, & has a
|| || || || || || || || || || || || ||
medical diagnosis of diabetes insipidus. The nurse chooses which of the
|| || || || || || || || || || ||
following nursing diagnoses as most appropriate? || || || || ||
1. Risk for Imbalanced Fluid Volume
|| || || || ||
2. Excess Fluid Volume
|| || ||
3. Imbalanced Nutrition
|| ||
4. Ineffective Tissue Perfusion - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || || ||
Rationale 1: The pt with excessive thirst, increased urination & a medical
|| || || || || || || || || || || ||
diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to
|| || || || || || || || || || || || ||
the pt &'s excess volume loss that can increase the serum levels of sodium.
|| || || || || || || || || || || || ||
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes
|| || || || || || || || || || || || ||
insipidus, especially during the early stages of treatment.
|| || || || || || || ||
Rationale 3: Imbalanced Nutrition does not apply. || || || || || ||
Rationale 4: Ineffective Tissue Perfusion does not apply|| || || || || || ||
, 2
A pt recovering from surgery has an indwelling urinary catheter. The nurse
|| || || || || || || || || || || ||
would contact the pt's primary healthcare provider with which of the
|| || || || || || || || || || ||
following 24-hour urine output volumes?|| || || ||
1. 600 mL
|| ||
2. 750 mL
|| ||
3. 1000 mL
|| ||
4. 1200 mL - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || ||
Rationale 1: A urine output of less than 30 mL per hour must be reported to
|| || || || || || || || || || || || || || || ||
the primary healthcare provider. This indicates inadequate renal perfusion,
|| || || || || || || || ||
placing the pt at increased risk for acute renal failure & inadequate tissue
|| || || || || || || || || || || || ||
perfusion. A minimum of 720 mL over a 24-hour period is desired (30 mL
|| || || || || || || || || || || || || ||
multiplied by 24 hours equals 720 mL per 24 hours).
|| || || || || || || || ||
A pt is receiving intravenous fluids postoperatively following cardiac surgery.
|| || || || || || || || || ||
Nursing assessments should focus on which postoperative complication?
|| || || || || || ||
1. fluid volume excess
|| || ||
2. fluid volume deficit
|| || ||
3. seizure activity
|| ||
4. liver failure - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || ||
Rationale 1: Antidiuretic hormone & aldosterone levels are commonly
|| || || || || || || || ||
increased following the stress response before, during, & immediately after
|| || || || || || || || || ||
surgery. This increase leads to sodium & water retention. Adding more fluids
|| || || || || || || || || || || ||
intravenously can cause a fluid volume excess & stress upon the heart &
|| || || || || || || || || || || || ||
circulatory system. ||
Rationale 2: Adding more fluids intravenously can cause a fluid volume
|| || || || || || || || || || ||
excess, not fluid volume deficit, & stress upon the heart & circulatory system.
|| || || || || || || || || || || ||
NCLEX Fluid and Electrolytes || || || ||
Questions With Answers || || ||
What is the nurse's primary concern regarding fluid & electrolytes when
|| || || || || || || || || || ||
caring for an elderly pt who is intermittently confused?
|| || || || || || || ||
1. risk of dehydration
|| || ||
2. risk of kidney damage
|| || || ||
3. risk of stroke
|| || ||
4. risk of bleeding - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || || ||
Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a
|| || || || || || || || || || || || || ||
pt with an altered level of consciousness, there is an increased risk of
|| || || || || || || || || || || || ||
dehydration & high serum osmolality. || || || ||
Rationale 2: The risks for kidney damage are not specifically related to aging
|| || || || || || || || || || || || ||
or fluid & electrolyte issues.
|| || || ||
Rationale 3: The risk of stroke is not specifically related to aging or fluid &
|| || || || || || || || || || || || || || ||
electrolyte issues. ||
Rationale 4: The risk of bleeding is not specifically related to aging or fluid &
|| || || || || || || || || || || || || || ||
electrolyte issues. ||
The nurse is planning care for a pt with severe burns. Which of the following
|| || || || || || || || || || || || || || ||
is this pt at risk for developing?
|| || || || || ||
1. intracellular fluid deficit
|| || ||
2. intracellular fluid overload
|| || ||
, 2
3. extracellular fluid deficit
|| || ||
4. interstitial fluid deficit - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || || ||
Rationale 1: Because this pt was severely burned, the fluid within the cells is
|| || || || || || || || || || || || || ||
diminished, leading to an intracellular fluid deficit.|| || || || || ||
Rationale 2: The intracellular fluid is all fluids that exist within the cell
|| || || || || || || || || || || || ||
cytoplasm & nucleus. Because this pt was severely burned, the fluid within
|| || || || || || || || || || || ||
the cells is diminished, leading to an intracellular fluid deficit.
|| || || || || || || || ||
Rationale 3: The extracellular fluid is all fluids that exist outside the cell,
|| || || || || || || || || || || || ||
including the interstitial fluid between the cells. Because this pt was severely
|| || || || || || || || || || || ||
burned, the fluid within the cells is diminished, leading to an intracellular
|| || || || || || || || || || || ||
fluid deficit.
||
Rationale 4: The extracellular fluid is all fluids that exist outside the cell,
|| || || || || || || || || || || || ||
including the interstitial fluid between the cells. Because this pt was severely
|| || || || || || || || || || || ||
burned, the fluid within the cells is diminished, leading to an intracellular
|| || || || || || || || || || || ||
fluid deficit.
||
A pt, experiencing multisystem fluid volume deficit, has the symptoms of
|| || || || || || || || || || ||
tachycardia, pale, cool skin, & decreased urine output. The nurse realizes
|| || || || || || || || || || ||
these findings are most likely a direct result of which of the following?
|| || || || || || || || || || || ||
1. the body's natural compensatory mechanisms
|| || || || ||
2. pharmacological effects of a diuretic
|| || || || ||
3. effects of rapidly infused intravenous fluids
|| || || || || ||
4. cardiac failure - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || ||
, 2
Rationale 1: The internal vasoconstrictive compensatory reactions within the
|| || || || || || || || ||
body are responsible for the symptoms exhibited. The body naturally attempts
|| || || || || || || || || ||
to conserve fluid internally specifically for the brain & heart.
|| || || || || || || || || ||
Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
|| || || || || || || || || || ||
Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in
|| || || || || || || || || || || ||
urine output. ||
Rationale 4: The manifestations reported are not indicative of cardiac failure
|| || || || || || || || || || ||
in this pt.
|| ||
A pregnant pt is admitted with excessive thirst, increased urination, & has a
|| || || || || || || || || || || || ||
medical diagnosis of diabetes insipidus. The nurse chooses which of the
|| || || || || || || || || || ||
following nursing diagnoses as most appropriate? || || || || ||
1. Risk for Imbalanced Fluid Volume
|| || || || ||
2. Excess Fluid Volume
|| || ||
3. Imbalanced Nutrition
|| ||
4. Ineffective Tissue Perfusion - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || || ||
Rationale 1: The pt with excessive thirst, increased urination & a medical
|| || || || || || || || || || || ||
diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to
|| || || || || || || || || || || || ||
the pt &'s excess volume loss that can increase the serum levels of sodium.
|| || || || || || || || || || || || ||
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes
|| || || || || || || || || || || || ||
insipidus, especially during the early stages of treatment.
|| || || || || || || ||
Rationale 3: Imbalanced Nutrition does not apply. || || || || || ||
Rationale 4: Ineffective Tissue Perfusion does not apply|| || || || || || ||
, 2
A pt recovering from surgery has an indwelling urinary catheter. The nurse
|| || || || || || || || || || || ||
would contact the pt's primary healthcare provider with which of the
|| || || || || || || || || || ||
following 24-hour urine output volumes?|| || || ||
1. 600 mL
|| ||
2. 750 mL
|| ||
3. 1000 mL
|| ||
4. 1200 mL - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || ||
Rationale 1: A urine output of less than 30 mL per hour must be reported to
|| || || || || || || || || || || || || || || ||
the primary healthcare provider. This indicates inadequate renal perfusion,
|| || || || || || || || ||
placing the pt at increased risk for acute renal failure & inadequate tissue
|| || || || || || || || || || || || ||
perfusion. A minimum of 720 mL over a 24-hour period is desired (30 mL
|| || || || || || || || || || || || || ||
multiplied by 24 hours equals 720 mL per 24 hours).
|| || || || || || || || ||
A pt is receiving intravenous fluids postoperatively following cardiac surgery.
|| || || || || || || || || ||
Nursing assessments should focus on which postoperative complication?
|| || || || || || ||
1. fluid volume excess
|| || ||
2. fluid volume deficit
|| || ||
3. seizure activity
|| ||
4. liver failure - CORRECT ANSWER(S)✔✔Answer: 1
|| || || || || ||
Rationale 1: Antidiuretic hormone & aldosterone levels are commonly
|| || || || || || || || ||
increased following the stress response before, during, & immediately after
|| || || || || || || || || ||
surgery. This increase leads to sodium & water retention. Adding more fluids
|| || || || || || || || || || || ||
intravenously can cause a fluid volume excess & stress upon the heart &
|| || || || || || || || || || || || ||
circulatory system. ||
Rationale 2: Adding more fluids intravenously can cause a fluid volume
|| || || || || || || || || || ||
excess, not fluid volume deficit, & stress upon the heart & circulatory system.
|| || || || || || || || || || || ||
