Fluids & Electrolytes NCLEX Questions
The nurse is caring for a patient with a massive burn injury and possible
hypovolemia. Which assessment data will be of most concern to the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum. -
ANS: B
The blood pressure indicates that the patient may be developing hypovolemic shock as a
result of
intravascular fluid loss because of the burn injury. This finding will require immediate
intervention
to prevent the complications associated with systemic hypoperfusion. The poor oral intake,
decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid
intake but not as urgently as the hypotension.
A patient who has a small cell carcinoma of the lung develops syndrome of
inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care
provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours -
ANS: B
Hyponatremia is the most important finding to report. SIADH causes water retention and a
decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous
system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine
output
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,indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected
with
SIADH because of water retention.
A patient with multiple draining wounds is admitted for hypovolemia. Which
assessment would be the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor c. Urine output
b. Daily weight d. Edema presence -
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
fluid
moves into the interstitial space and causes edema. Urine outputs do not take account of fluid
intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract
or
wounds.
The home health nurse cares for an alert and oriented older adult patient with a
history of dehydration. Which instructions should the nurse give this patient related to fluid
intake?
a. "Drink more fluids in the late evening."
b. "Increase fluids if your mouth feels dry."
c. "More fluids are needed if you feel thirsty."
d. "If you feel confused, you need more to drink." -
ANS: B
An alert older patient will be able to self-assess for signs of oral dryness such as thick oral
secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in
the
evening to improve sleep quality. The patient will not be likely to notice and act appropriately
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,when changes in level of consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment of
hypertension complains of generalized weakness. Which action is appropriate for the nurse
to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel. -
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health care provider
orders the
metabolic panel, the nurse should check the potassium level. Facial muscle spasms might
occur
with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the
patient is hypokalemic. Loose stools are associated with hyperkalemia.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a
patient. Which statement by the patient indicates that the teaching about this medication has
been effective?
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast." -
ANS: D
Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose
low-
potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium
(e.g.,
citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not
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, encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which
are
high in potassium.
A patient with new-onset confusion and hyponatremia is being admitted. When
making room assignments, the charge nurse should take which action?
a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurse's station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves.. -
ANS: B
The patient should be placed near the nurse's station if confused for the staff to closely
monitor the
patient. To help improve serum sodium levels, water intake is restricted. Therefore a
confused
patient should not be placed near a water fountain. Peaked T waves are a sign of
hyperkalemia, not
hyponatremia. A confused patient could be distracting and disruptive for another patient in a
semiprivate room.
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with
severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 10 mEq/hour.
c. Only give the KCl through a central venous line.
d. Discontinue cardiac monitoring during the infusion. -
ANS: B
IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause
cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by
this
4|Page
The nurse is caring for a patient with a massive burn injury and possible
hypovolemia. Which assessment data will be of most concern to the nurse?
a. Urine output is 30 mL/hr.
b. Blood pressure is 90/40 mm Hg.
c. Oral fluid intake is 100 mL for the past 8 hours.
d. There is prolonged skin tenting over the sternum. -
ANS: B
The blood pressure indicates that the patient may be developing hypovolemic shock as a
result of
intravascular fluid loss because of the burn injury. This finding will require immediate
intervention
to prevent the complications associated with systemic hypoperfusion. The poor oral intake,
decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid
intake but not as urgently as the hypotension.
A patient who has a small cell carcinoma of the lung develops syndrome of
inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care
provider about which assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium level of 120 mg/dL
c. Reported weight gain of 2.2 lb (1 kg)
d. Urinary output of 280 mL during past 8 hours -
ANS: B
Hyponatremia is the most important finding to report. SIADH causes water retention and a
decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous
system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine
output
1|Page
,indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected
with
SIADH because of water retention.
A patient with multiple draining wounds is admitted for hypovolemia. Which
assessment would be the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor c. Urine output
b. Daily weight d. Edema presence -
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
fluid
moves into the interstitial space and causes edema. Urine outputs do not take account of fluid
intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract
or
wounds.
The home health nurse cares for an alert and oriented older adult patient with a
history of dehydration. Which instructions should the nurse give this patient related to fluid
intake?
a. "Drink more fluids in the late evening."
b. "Increase fluids if your mouth feels dry."
c. "More fluids are needed if you feel thirsty."
d. "If you feel confused, you need more to drink." -
ANS: B
An alert older patient will be able to self-assess for signs of oral dryness such as thick oral
secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in
the
evening to improve sleep quality. The patient will not be likely to notice and act appropriately
2|Page
,when changes in level of consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment of
hypertension complains of generalized weakness. Which action is appropriate for the nurse
to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel. -
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health care provider
orders the
metabolic panel, the nurse should check the potassium level. Facial muscle spasms might
occur
with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the
patient is hypokalemic. Loose stools are associated with hyperkalemia.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a
patient. Which statement by the patient indicates that the teaching about this medication has
been effective?
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast." -
ANS: D
Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose
low-
potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium
(e.g.,
citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not
3|Page
, encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which
are
high in potassium.
A patient with new-onset confusion and hyponatremia is being admitted. When
making room assignments, the charge nurse should take which action?
a. Assign the patient to a semi-private room.
b. Assign the patient to a room near the nurse's station.
c. Place the patient in a room nearest to the water fountain.
d. Place the patient on telemetry to monitor for peaked T waves.. -
ANS: B
The patient should be placed near the nurse's station if confused for the staff to closely
monitor the
patient. To help improve serum sodium levels, water intake is restricted. Therefore a
confused
patient should not be placed near a water fountain. Peaked T waves are a sign of
hyperkalemia, not
hyponatremia. A confused patient could be distracting and disruptive for another patient in a
semiprivate room.
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with
severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 10 mEq/hour.
c. Only give the KCl through a central venous line.
d. Discontinue cardiac monitoring during the infusion. -
ANS: B
IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause
cardiac arrest. KCl can cause inflammation of peripheral veins, but it can be administered by
this
4|Page
