NCLEX Fluid & Electrolyte Exam Questions and Answers A Score

NCLEX Fluid & Electrolyte Exam Questions and Answers A Score 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 - 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 3. extracellular fluid deficit 4. interstitial fluid deficit - 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 - Answer: 1 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 - 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 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 - 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 - 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. Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances. Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid administration. A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented? 1. seizure 2. infection 3. neutropenic 4. high-risk fall - Answer: 1 Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included. Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia. Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia. Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia. A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the following might have contributed to the pt's health problem? 1. corticosteroid 2. thiazide diuretic 3. narcotic 4. muscle relaxer - Answer: 1 Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics. Rationale 2: Excessive sodium is lost with the use of thiazide diuretics. Rationale 3: Narcotics do not typically affect electrolyte balance. Rationale 4: Muscle relaxants do not typically affect electrolyte balance. A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following? 1. hyperkalemia 2. hypokalemia 3. hypercalcemia 4. hypocalcemia - Answer: 1 Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes. Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide. Rationale 3: Hypercalcemia has been associated with thiazide diuretics. Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is not associated with diuretic use. The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt's plan of care? 1. Restrict fluids. 2. Administer intravenous fluids. 3. Provide Kayexalate. 4. Administer intravenous normal saline with furosemide. - Answer: 1 Rationale 1: The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from dropping further due to dilution. Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit & hypernatremia. Rationale 3: Kayexalate is used in pts with hyperkalemia. Rationale 4: The administration of normal saline with furosemide is used to increase calcium secretion.