FLUID AND ELECTROLYTE NCLEX LATEST UPDATE) REAL
QUESTIONS AND VERIFIED ANSWERS |100% CORRECT |
ALREADY GRADED A
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?
1 - weight loss
2 - Flat neck and head veins
3 - An increase in BP
4 - Decreased central venous pressure Ans✓✓✓3 - Increase in BP
Reason:
-Dyspneic - difficulty breathing and crackles are findings of fluid
volume excess (overhydration)
-The other symptoms would not match because they should be the
opposite (weight gain, distended veins, elevated CVP)
The nurse is preparing to care for a client with a potassium deficit. The
nurse reviews the client record and determines that the client was at risk
for developing the potassium deficit because of which situation?
1 - Sustained tissue damage
2 - Requires nasogastric suction
,3 - Has a history of Addison's disease
4 - Is taking potassium-retaining diuretics Ans✓✓✓2 - Required
nasogastric suction
Reason:
- Hyopkalemia - potassium deficit (normal levels 3.5 mEq/L - 5.0
mEq/L)
- The other points are risks for HYPERkalemia
The nurse reviews a client's electrolyte laboratory report and notes that
the potassium level is 2.5 mEq/L. Which pattern would the nurse note on
the electrolyte cardiogram as a result of the lab value?
1 - U waves
2 - Absent P waves
3 - Elevated T waves
4 - Elevated ST segment Ans✓✓✓1 - U waves
Reason:
- Level is below normal limit (HYPO)
- This results in the following ECG results: ST depression,
shallow/flat/inverted T wave, prominent U wave
,The nursing student needs to administer potassium chloride IV as
prescribed to client with hypokalemia. The instructor determines that the
student is unprepared if the student states that which action is part of the
plan for preparation and administration of the potassium?
1 - obtaining IV infusion pump
2 - Monitoring urine output during administration
3 - Preparing the medication for bolus administration
4 - Ensuring the med is diluted in the appropriate amount of normal
saline Ans✓✓✓3 - Preparing for bolus administration
Reason:
- Bolus = IV push
- Potassium is NEVER given by IV push (AKA bolus)
The nurse provides instructions to a client with a low potassium level
about the foods that are high in potassium and tells them to consume
which of the following (select all that apply)?
1 - Peas
2 - Raisins
3 - Potatoes
4 - Cantaloupe
, 5 - Cauliflower
6 - Strawberries Ans✓✓✓Raisins, Potatoes, cantaloupe, strawberries
The nurse is reviewing lab results and notes that a client's serum sodium
level is 150 mEq/L. The nurse reports the level to the health care
provider and they prescribe dietary instructions based on the sodium
level. Which food does the client need to avoid?
1 - Peas
2 - Nuts
3 - Cauliflower
4 - Processed oat cereals Ans✓✓✓4 - Processed oat cereal
Reason:
- Normal levels: 135 - 145 mEq/L
- The patient has an elevated level meaning they should not consume
sodium rich foods, and processed foods have elevated amounts of
sodium
The nurse is assessing a client with a suspected diagnosis of
hypocalcemia. Which clinical manifestation would the nurse expect to
note?
1 - twitching
QUESTIONS AND VERIFIED ANSWERS |100% CORRECT |
ALREADY GRADED A
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?
1 - weight loss
2 - Flat neck and head veins
3 - An increase in BP
4 - Decreased central venous pressure Ans✓✓✓3 - Increase in BP
Reason:
-Dyspneic - difficulty breathing and crackles are findings of fluid
volume excess (overhydration)
-The other symptoms would not match because they should be the
opposite (weight gain, distended veins, elevated CVP)
The nurse is preparing to care for a client with a potassium deficit. The
nurse reviews the client record and determines that the client was at risk
for developing the potassium deficit because of which situation?
1 - Sustained tissue damage
2 - Requires nasogastric suction
,3 - Has a history of Addison's disease
4 - Is taking potassium-retaining diuretics Ans✓✓✓2 - Required
nasogastric suction
Reason:
- Hyopkalemia - potassium deficit (normal levels 3.5 mEq/L - 5.0
mEq/L)
- The other points are risks for HYPERkalemia
The nurse reviews a client's electrolyte laboratory report and notes that
the potassium level is 2.5 mEq/L. Which pattern would the nurse note on
the electrolyte cardiogram as a result of the lab value?
1 - U waves
2 - Absent P waves
3 - Elevated T waves
4 - Elevated ST segment Ans✓✓✓1 - U waves
Reason:
- Level is below normal limit (HYPO)
- This results in the following ECG results: ST depression,
shallow/flat/inverted T wave, prominent U wave
,The nursing student needs to administer potassium chloride IV as
prescribed to client with hypokalemia. The instructor determines that the
student is unprepared if the student states that which action is part of the
plan for preparation and administration of the potassium?
1 - obtaining IV infusion pump
2 - Monitoring urine output during administration
3 - Preparing the medication for bolus administration
4 - Ensuring the med is diluted in the appropriate amount of normal
saline Ans✓✓✓3 - Preparing for bolus administration
Reason:
- Bolus = IV push
- Potassium is NEVER given by IV push (AKA bolus)
The nurse provides instructions to a client with a low potassium level
about the foods that are high in potassium and tells them to consume
which of the following (select all that apply)?
1 - Peas
2 - Raisins
3 - Potatoes
4 - Cantaloupe
, 5 - Cauliflower
6 - Strawberries Ans✓✓✓Raisins, Potatoes, cantaloupe, strawberries
The nurse is reviewing lab results and notes that a client's serum sodium
level is 150 mEq/L. The nurse reports the level to the health care
provider and they prescribe dietary instructions based on the sodium
level. Which food does the client need to avoid?
1 - Peas
2 - Nuts
3 - Cauliflower
4 - Processed oat cereals Ans✓✓✓4 - Processed oat cereal
Reason:
- Normal levels: 135 - 145 mEq/L
- The patient has an elevated level meaning they should not consume
sodium rich foods, and processed foods have elevated amounts of
sodium
The nurse is assessing a client with a suspected diagnosis of
hypocalcemia. Which clinical manifestation would the nurse expect to
note?
1 - twitching
