Fluid and Electrolytes NCLEX Questions
with correct answers
The |RN |is |assessing |a |70-year-old |client |admitted |to |the |unit |with |severe |dehydration. |Which |finding |
requires |immediate |intervention |by |the |nurse?
A. |Client |behavior |that |changes |from |anxious |to |lethargic
B. |Deep |furrows |on |the |surface |of |the |tongue
C. |Poor |skin |turgor |with |tenting |remaining |for |2 |minutes |after |the |skin |is |pinched
D. |Urine |output |of |950 |mL |for |the |past |24 |hours |- |✔✔A. |Client |behavior |that |changes |from |anxious |
to |lethargic
RATIONALE: |
Immediate |intervention |by |the |nurse |is |required |when |a |client's |behavior |changes |from |anxious |to |
lethargic. |This |change |in |mental |status |suggests |poor |cerebral |blood |flow |and |fluid |shifts |within |the |
brain |cells. |Immediate |intervention |is |needed |to |prevent |further |cerebral |dysfunction.Deep |furrows |
on |the |surface |of |the |tongue, |poor |skin |turgor, |and |low |urine |output |are |all |caused |by |the |fluid |
volume |deficit, |but |do |not |indicate |complications |of |dehydration |that |are |immediately |life-
threatening.
A |client |with |diarrhea |for |3 |days |and |inability |to |eat |or |drink |well |is |brought |to |the |emergency |
department |(ED) |by |her |family. |She |states |she |has |been |taking |her |diuretics |for |congestive |heart |
failure |(CHF). |What |nursing |actions |are |indicated |at |this |time?
SELECT |ALL |THAT |APPLY.
A. |Place |the |client |on |bed |rest.
B. |Evaluate |the |electrolyte |levels.
C. |Administer |the |ordered |diuretic.
D. |Assess |for |orthostatic |hypotension
,E. |Initiate |cardiac |monitoring. |- |✔✔A, |B, |D, |E
RATIONALE:
Nursing |actions |indicated |at |this |time |include: |placing |the |client |on |bedrest |and |assisting |the |client |
out |of |bed, |evaluating |electrolyte |levels, |assessing |for |orthostatic |hypotension, |and |applying |a |cardiac
|monitor. |Safety |is |required |to |prevent |falls |due |to |weakness |from |a |likely |fluid |volume |deficit |and |
electrolyte |imbalance. |The |nurse |should |review |the |laboratory |and |diagnostic |results |to |detect |likely |
loss |of |sodium, |potassium, |and |magnesium |secondary |to |diarrhea |and |diuretic |us. |Fluid |volume |deficit
|is |likely |with |diarrhea |and |diuretic |use |and |leads |to |fluid |and |electrolyte |imbalances, |especially |
hypokalemia. |Assessing |for |orthostatic |changes |will |confirm |presence |of |volume |deficit. |Monitoring |
for |inverted |T |wave |or |presence |of |U |wave |on |the |ECG |as |well |as |dysrhythmias |is |indicated |when |
hypokalemia |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.
A |client |with |hypokalemia |has |a |prescription |for |parenteral |potassium |chloride |(KCl). |Which |of |these |
interventions |does |the |nurse |use |to |safely |administer |KCl?
SELECT |ALL |THAT |APPLY. |
A. |Use |a |potassium |infusion |prepared |by |a |registered |pharmacist.
B. |Assess |for |burning |or |redness |during |infusion.
C. |Infuse |at |a |rate |of |no |more |than |10 |mEq |per |hour.
D. |Administer |only |through |a |central |venous |catheter.
E. |Administer |by |IV |push |only |during |cardiac |arrest. |- |✔✔A, |B, |C
RATIONALE:
Interventions |to |safely |administer |KCl |to |a |client |with |hypokalemia |include: |using |a |pharmacy |
prepared |potassium |infusion, |checking |the |client |for |any |burning |or |redness |during |infusion, |and |
infusing |the |IV |at |not |more |than |10 |mEq |per |hour. |The |Joint |Commission's |National |Client |Safety |
Goals |mandates |that |concentrated |potassium |be |diluted |and |added |to |IV |solutions |only |in |the |
pharmacy |by |a |registered |pharmacist |and |that |vials |of |concentrated |potassium |not |be |available |in |
client |care |areas. |IV |potassium |solutions |irritate |veins |and |cause |phlebitis. |Assess |the |IV |site |hourly, |
and |ask |the |client |whether |he |or |she |feels |burning |or |pain |at |the |site. |The |presence |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.
The |nurse |is |caring |for |a |client |who |is |receiving |a |loop |diuretic |for |treatment |of |heart |failure. |Which |
of |these |actions |will |be |included |in |the |plan |of |care? |
, SELECT |ALL |THAT |APPLY. |
A. |Assess |daily |weights.
B. |Encourage |consumption |of |citrus |fruits.
C. |Weigh |the |client |weekly.
D. |Monitor |serum |potassium.
E. |Discourage |intake |of |spinach.
F. |Monitor |for |bradycardia. |- |✔✔A, |B, |D
RATIONALE:
Actions |for |the |nurse |to |include |when |caring |for |a |client |taking |a |loop |diuretic |for |heart |failure |
include: |assessing |daily |weights, |encouraging |consumption |of |citrus |fruits, |and |monitoring |the |client's |
serum |potassium. |High-ceiling |(loop) |diuretics |remove |excess |fluid |and |are |potassium-depleting |drugs.
|Consuming |citrus |fruit, |green |leafy |vegetables, |cantaloupe, |tomato, |and |other |food |with |potassium |is
|indicated |while |receiving |this |type |of |diuretic |to |compensate |for |urinary |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 |depletion |caused |
by |the |diuretic |may |cause |cardiac |irritability |with |a |weak |and |thready |pulse.
The |nurse |is |caring |for |a |client |who |takes |furosemide |(Lasix) |and |digoxin |(Lanoxin). |The |client's |
potassium |(K+) |level |is |2.5 |mEq/L |(2.5 |mmol/L). |Which |additional |assessment |will |the |nurse |make?
A. |Heart |rate
B. |Blood |pressure |(BP)
C. |Increases |in |edema |
D. |Sodium |level |- |✔✔A. |Heart |rate
RATIONALE:
The |nurse |must |assess |the |heart |rate |for |bradycardia |related |to |digoxin |and |irritability |or |irregularity |
related |to |hypokalemia. |Hypokalemia |increases |the |sensitivity |of |cardiac |muscle |to |digoxin |and |may |
result |in |digoxin |toxicity, |even |when |the |digoxin |level |is |within |the |therapeutic |range. |The |nurse |also |
assesses |for |GI |symptoms |such |as |diarrhea, |and |other |symptoms |of |toxicity |to |digoxin.The |BP |may |
decrease |with |low |potassium |level |but |monitoring |the |pulse |is |essential. |The |diuretic |would |reduce |
edema, |therefore |assessing |the |heart |rate |is |the |priority. |High |serum |sodium |levels |would |not |be |
expected |in |this |scenario |unless |fluid |volume |deficit |is |present.
with correct answers
The |RN |is |assessing |a |70-year-old |client |admitted |to |the |unit |with |severe |dehydration. |Which |finding |
requires |immediate |intervention |by |the |nurse?
A. |Client |behavior |that |changes |from |anxious |to |lethargic
B. |Deep |furrows |on |the |surface |of |the |tongue
C. |Poor |skin |turgor |with |tenting |remaining |for |2 |minutes |after |the |skin |is |pinched
D. |Urine |output |of |950 |mL |for |the |past |24 |hours |- |✔✔A. |Client |behavior |that |changes |from |anxious |
to |lethargic
RATIONALE: |
Immediate |intervention |by |the |nurse |is |required |when |a |client's |behavior |changes |from |anxious |to |
lethargic. |This |change |in |mental |status |suggests |poor |cerebral |blood |flow |and |fluid |shifts |within |the |
brain |cells. |Immediate |intervention |is |needed |to |prevent |further |cerebral |dysfunction.Deep |furrows |
on |the |surface |of |the |tongue, |poor |skin |turgor, |and |low |urine |output |are |all |caused |by |the |fluid |
volume |deficit, |but |do |not |indicate |complications |of |dehydration |that |are |immediately |life-
threatening.
A |client |with |diarrhea |for |3 |days |and |inability |to |eat |or |drink |well |is |brought |to |the |emergency |
department |(ED) |by |her |family. |She |states |she |has |been |taking |her |diuretics |for |congestive |heart |
failure |(CHF). |What |nursing |actions |are |indicated |at |this |time?
SELECT |ALL |THAT |APPLY.
A. |Place |the |client |on |bed |rest.
B. |Evaluate |the |electrolyte |levels.
C. |Administer |the |ordered |diuretic.
D. |Assess |for |orthostatic |hypotension
,E. |Initiate |cardiac |monitoring. |- |✔✔A, |B, |D, |E
RATIONALE:
Nursing |actions |indicated |at |this |time |include: |placing |the |client |on |bedrest |and |assisting |the |client |
out |of |bed, |evaluating |electrolyte |levels, |assessing |for |orthostatic |hypotension, |and |applying |a |cardiac
|monitor. |Safety |is |required |to |prevent |falls |due |to |weakness |from |a |likely |fluid |volume |deficit |and |
electrolyte |imbalance. |The |nurse |should |review |the |laboratory |and |diagnostic |results |to |detect |likely |
loss |of |sodium, |potassium, |and |magnesium |secondary |to |diarrhea |and |diuretic |us. |Fluid |volume |deficit
|is |likely |with |diarrhea |and |diuretic |use |and |leads |to |fluid |and |electrolyte |imbalances, |especially |
hypokalemia. |Assessing |for |orthostatic |changes |will |confirm |presence |of |volume |deficit. |Monitoring |
for |inverted |T |wave |or |presence |of |U |wave |on |the |ECG |as |well |as |dysrhythmias |is |indicated |when |
hypokalemia |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.
A |client |with |hypokalemia |has |a |prescription |for |parenteral |potassium |chloride |(KCl). |Which |of |these |
interventions |does |the |nurse |use |to |safely |administer |KCl?
SELECT |ALL |THAT |APPLY. |
A. |Use |a |potassium |infusion |prepared |by |a |registered |pharmacist.
B. |Assess |for |burning |or |redness |during |infusion.
C. |Infuse |at |a |rate |of |no |more |than |10 |mEq |per |hour.
D. |Administer |only |through |a |central |venous |catheter.
E. |Administer |by |IV |push |only |during |cardiac |arrest. |- |✔✔A, |B, |C
RATIONALE:
Interventions |to |safely |administer |KCl |to |a |client |with |hypokalemia |include: |using |a |pharmacy |
prepared |potassium |infusion, |checking |the |client |for |any |burning |or |redness |during |infusion, |and |
infusing |the |IV |at |not |more |than |10 |mEq |per |hour. |The |Joint |Commission's |National |Client |Safety |
Goals |mandates |that |concentrated |potassium |be |diluted |and |added |to |IV |solutions |only |in |the |
pharmacy |by |a |registered |pharmacist |and |that |vials |of |concentrated |potassium |not |be |available |in |
client |care |areas. |IV |potassium |solutions |irritate |veins |and |cause |phlebitis. |Assess |the |IV |site |hourly, |
and |ask |the |client |whether |he |or |she |feels |burning |or |pain |at |the |site. |The |presence |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.
The |nurse |is |caring |for |a |client |who |is |receiving |a |loop |diuretic |for |treatment |of |heart |failure. |Which |
of |these |actions |will |be |included |in |the |plan |of |care? |
, SELECT |ALL |THAT |APPLY. |
A. |Assess |daily |weights.
B. |Encourage |consumption |of |citrus |fruits.
C. |Weigh |the |client |weekly.
D. |Monitor |serum |potassium.
E. |Discourage |intake |of |spinach.
F. |Monitor |for |bradycardia. |- |✔✔A, |B, |D
RATIONALE:
Actions |for |the |nurse |to |include |when |caring |for |a |client |taking |a |loop |diuretic |for |heart |failure |
include: |assessing |daily |weights, |encouraging |consumption |of |citrus |fruits, |and |monitoring |the |client's |
serum |potassium. |High-ceiling |(loop) |diuretics |remove |excess |fluid |and |are |potassium-depleting |drugs.
|Consuming |citrus |fruit, |green |leafy |vegetables, |cantaloupe, |tomato, |and |other |food |with |potassium |is
|indicated |while |receiving |this |type |of |diuretic |to |compensate |for |urinary |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 |depletion |caused |
by |the |diuretic |may |cause |cardiac |irritability |with |a |weak |and |thready |pulse.
The |nurse |is |caring |for |a |client |who |takes |furosemide |(Lasix) |and |digoxin |(Lanoxin). |The |client's |
potassium |(K+) |level |is |2.5 |mEq/L |(2.5 |mmol/L). |Which |additional |assessment |will |the |nurse |make?
A. |Heart |rate
B. |Blood |pressure |(BP)
C. |Increases |in |edema |
D. |Sodium |level |- |✔✔A. |Heart |rate
RATIONALE:
The |nurse |must |assess |the |heart |rate |for |bradycardia |related |to |digoxin |and |irritability |or |irregularity |
related |to |hypokalemia. |Hypokalemia |increases |the |sensitivity |of |cardiac |muscle |to |digoxin |and |may |
result |in |digoxin |toxicity, |even |when |the |digoxin |level |is |within |the |therapeutic |range. |The |nurse |also |
assesses |for |GI |symptoms |such |as |diarrhea, |and |other |symptoms |of |toxicity |to |digoxin.The |BP |may |
decrease |with |low |potassium |level |but |monitoring |the |pulse |is |essential. |The |diuretic |would |reduce |
edema, |therefore |assessing |the |heart |rate |is |the |priority. |High |serum |sodium |levels |would |not |be |
expected |in |this |scenario |unless |fluid |volume |deficit |is |present.
