Fluid and Electrolytes NCLEX Questions with 100% Verified Answer
1. The RN is assessing a A. Client behavior that changes from anxious
70-year-old client admitted to lethargic
to the unit with severe de-
hydration. Which finding re- RATIONALE:
quires immediate interven- Immediate intervention by the nurse is re-
tion by the nurse? quired when a client's behavior changes from
anxious to lethargic. This change in mental
A. Client behavior that status suggests poor cerebral blood flow and
changes from anxious to fluid shifts within the brain cells. Immediate
lethargic intervention is needed to prevent further cere-
B. Deep furrows on the sur- bral dysfunction.Deep furrows on the surface
face of the tongue of the tongue, poor skin turgor, and low urine
C. Poor skin turgor with tent- output are all caused by the fluid volume
ing remaining for 2 minutes deficit, but do not indicate complications of
after the skin is pinched dehydration that are immediately life-threat-
D. Urine output of 950 mL for ening.
the past 24 hours
2. A client with diarrhea for 3 A, B, D, E
days and inability to eat or
drink well is brought to the RATIONALE:
emergency department (ED) Nursing actions indicated at this time include:
by her family. She states she placing the client on bedrest and assisting
has been taking her diuretics the client out of bed, evaluating electrolyte
for congestive heart failure levels, assessing for orthostatic hypotension,
(CHF). What nursing actions and applying a cardiac monitor. Safety is re-
are indicated at this time? quired to prevent falls due to weakness from
SELECT ALL THAT APPLY. a likely fluid volume deficit and electrolyte im-
balance. The nurse should review the labora-
A. Place the client on bed tory and diagnostic results to detect likely loss
rest. of sodium, potassium, and magnesium sec-
B. Evaluate the electrolyte ondary to diarrhea and diuretic us. Fluid vol-
levels. ume deficit is likely with diarrhea and diuretic
C. Administer the ordered di- use and leads to fluid and electrolyte imbal-
uretic. ances, especially hypokalemia. Assessing for
D. Assess for orthostatic hy- orthostatic changes will confirm presence of
potension volume deficit. Monitoring for inverted T wave
E. Initiate cardiac monitor- or presence of U wave on the ECG as well as
ing. dysrhythmias is indicated when hypokalemia
,Fluid and Electrolytes NCLEX Questions with 100% Verified Answer
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.
3. A client with hypokalemia A, B, C
has a prescription for par-
enteral potassium chloride RATIONALE:
(KCl). Which of these inter- Interventions to safely administer KCl to a
ventions does the nurse use client with hypokalemia include: using a phar-
to safely administer KCl? macy prepared potassium infusion, checking
SELECT ALL THAT APPLY. the client for any burning or redness dur-
ing infusion, and infusing the IV at not more
A. Use a potassium infu- than 10 mEq per hour. The Joint Commis-
sion prepared by a registered sion's National Client Safety Goals mandates
pharmacist. that concentrated potassium be diluted and
B. Assess for burning or red- added to IV solutions only in the pharmacy
ness during infusion. by a registered pharmacist and that vials of
C. Infuse at a rate of no more concentrated potassium not be available in
than 10 mEq per hour. client care areas. IV potassium solutions irri-
D. Administer only through a tate veins and cause phlebitis. Assess the IV
central venous catheter. site hourly, and ask the client whether he or
E. Administer by IV push only she feels burning or pain at the site. The pres-
during cardiac arrest. ence 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.
4. The nurse is caring for a A, B, D
client who is receiving a loop
diuretic for treatment of heart RATIONALE:
failure. Which of these ac- Actions for the nurse to include when car-
tions will be included in the ing for a client taking a loop diuretic for
plan of care? heart failure include: assessing daily weights,
SELECT ALL THAT APPLY. encouraging consumption of citrus fruits,
, Fluid and Electrolytes NCLEX Questions with 100% Verified Answer
A. Assess daily weights. and monitoring the client's serum potassi-
B. Encourage consumption um. High-ceiling (loop) diuretics remove ex-
of citrus fruits. cess fluid and are potassium-depleting drugs.
C. Weigh the client weekly. Consuming citrus fruit, green leafy vegeta-
D. Monitor serum potassium. bles, cantaloupe, tomato, and other food with
E. Discourage intake of potassium is indicated while receiving this
spinach. type of diuretic to compensate for urinary
F. Monitor for bradycardia. 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 deple-
tion caused by the diuretic may cause cardiac
irritability with a weak and thready pulse.
5. The nurse is caring for a A. Heart rate
client who takes furosemide
(Lasix) and digoxin (Lanox- RATIONALE:
in). The client's potassium The nurse must assess the heart rate for
(K+) level is 2.5 mEq/L bradycardia related to digoxin and irritabili-
(2.5 mmol/L). Which addition- ty or irregularity related to hypokalemia. Hy-
al assessment will the nurse pokalemia increases the sensitivity of cardiac
make? muscle to digoxin and may result in digoxin
A. Heart rate toxicity, even when the digoxin level is with-
B. Blood pressure (BP) in the therapeutic range. The nurse also as-
C. Increases in edema sesses for GI symptoms such as diarrhea,
D. Sodium level and other symptoms of toxicity to digoxin.The
BP may decrease with low potassium lev-
el but monitoring the pulse is essential. The
diuretic would reduce edema, therefore as-
sessing the heart rate is the priority. High
serum sodium levels would not be expected
in this scenario unless fluid volume deficit is
present.
6. Furosemide (Lasix) has been C. The client is free from adventitious breath
ordered for a client with heart sounds.
1. The RN is assessing a A. Client behavior that changes from anxious
70-year-old client admitted to lethargic
to the unit with severe de-
hydration. Which finding re- RATIONALE:
quires immediate interven- Immediate intervention by the nurse is re-
tion by the nurse? quired when a client's behavior changes from
anxious to lethargic. This change in mental
A. Client behavior that status suggests poor cerebral blood flow and
changes from anxious to fluid shifts within the brain cells. Immediate
lethargic intervention is needed to prevent further cere-
B. Deep furrows on the sur- bral dysfunction.Deep furrows on the surface
face of the tongue of the tongue, poor skin turgor, and low urine
C. Poor skin turgor with tent- output are all caused by the fluid volume
ing remaining for 2 minutes deficit, but do not indicate complications of
after the skin is pinched dehydration that are immediately life-threat-
D. Urine output of 950 mL for ening.
the past 24 hours
2. A client with diarrhea for 3 A, B, D, E
days and inability to eat or
drink well is brought to the RATIONALE:
emergency department (ED) Nursing actions indicated at this time include:
by her family. She states she placing the client on bedrest and assisting
has been taking her diuretics the client out of bed, evaluating electrolyte
for congestive heart failure levels, assessing for orthostatic hypotension,
(CHF). What nursing actions and applying a cardiac monitor. Safety is re-
are indicated at this time? quired to prevent falls due to weakness from
SELECT ALL THAT APPLY. a likely fluid volume deficit and electrolyte im-
balance. The nurse should review the labora-
A. Place the client on bed tory and diagnostic results to detect likely loss
rest. of sodium, potassium, and magnesium sec-
B. Evaluate the electrolyte ondary to diarrhea and diuretic us. Fluid vol-
levels. ume deficit is likely with diarrhea and diuretic
C. Administer the ordered di- use and leads to fluid and electrolyte imbal-
uretic. ances, especially hypokalemia. Assessing for
D. Assess for orthostatic hy- orthostatic changes will confirm presence of
potension volume deficit. Monitoring for inverted T wave
E. Initiate cardiac monitor- or presence of U wave on the ECG as well as
ing. dysrhythmias is indicated when hypokalemia
,Fluid and Electrolytes NCLEX Questions with 100% Verified Answer
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.
3. A client with hypokalemia A, B, C
has a prescription for par-
enteral potassium chloride RATIONALE:
(KCl). Which of these inter- Interventions to safely administer KCl to a
ventions does the nurse use client with hypokalemia include: using a phar-
to safely administer KCl? macy prepared potassium infusion, checking
SELECT ALL THAT APPLY. the client for any burning or redness dur-
ing infusion, and infusing the IV at not more
A. Use a potassium infu- than 10 mEq per hour. The Joint Commis-
sion prepared by a registered sion's National Client Safety Goals mandates
pharmacist. that concentrated potassium be diluted and
B. Assess for burning or red- added to IV solutions only in the pharmacy
ness during infusion. by a registered pharmacist and that vials of
C. Infuse at a rate of no more concentrated potassium not be available in
than 10 mEq per hour. client care areas. IV potassium solutions irri-
D. Administer only through a tate veins and cause phlebitis. Assess the IV
central venous catheter. site hourly, and ask the client whether he or
E. Administer by IV push only she feels burning or pain at the site. The pres-
during cardiac arrest. ence 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.
4. The nurse is caring for a A, B, D
client who is receiving a loop
diuretic for treatment of heart RATIONALE:
failure. Which of these ac- Actions for the nurse to include when car-
tions will be included in the ing for a client taking a loop diuretic for
plan of care? heart failure include: assessing daily weights,
SELECT ALL THAT APPLY. encouraging consumption of citrus fruits,
, Fluid and Electrolytes NCLEX Questions with 100% Verified Answer
A. Assess daily weights. and monitoring the client's serum potassi-
B. Encourage consumption um. High-ceiling (loop) diuretics remove ex-
of citrus fruits. cess fluid and are potassium-depleting drugs.
C. Weigh the client weekly. Consuming citrus fruit, green leafy vegeta-
D. Monitor serum potassium. bles, cantaloupe, tomato, and other food with
E. Discourage intake of potassium is indicated while receiving this
spinach. type of diuretic to compensate for urinary
F. Monitor for bradycardia. 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 deple-
tion caused by the diuretic may cause cardiac
irritability with a weak and thready pulse.
5. The nurse is caring for a A. Heart rate
client who takes furosemide
(Lasix) and digoxin (Lanox- RATIONALE:
in). The client's potassium The nurse must assess the heart rate for
(K+) level is 2.5 mEq/L bradycardia related to digoxin and irritabili-
(2.5 mmol/L). Which addition- ty or irregularity related to hypokalemia. Hy-
al assessment will the nurse pokalemia increases the sensitivity of cardiac
make? muscle to digoxin and may result in digoxin
A. Heart rate toxicity, even when the digoxin level is with-
B. Blood pressure (BP) in the therapeutic range. The nurse also as-
C. Increases in edema sesses for GI symptoms such as diarrhea,
D. Sodium level and other symptoms of toxicity to digoxin.The
BP may decrease with low potassium lev-
el but monitoring the pulse is essential. The
diuretic would reduce edema, therefore as-
sessing the heart rate is the priority. High
serum sodium levels would not be expected
in this scenario unless fluid volume deficit is
present.
6. Furosemide (Lasix) has been C. The client is free from adventitious breath
ordered for a client with heart sounds.
