8/14/25, 4:57 PM Fluid and Electrolytes NCLEX
Fluid and Electrolytes NCLEX complete
questions and accurate detailed answers
verified 100% latest update 2025
The RN is assessing a 70- A. Client behavior that changes from anxious to
year-old client admitted lethargic
to the unit with severe
dehydration. Which finding RATIONALE:
requires immediate Immediate intervention by the nurse is required when
intervention by the nurse? a client's behavior changes from anxious to lethargic.
This change in mental status suggests poor cerebral
A. Client behavior that blood flow and fluid shifts within the brain cells.
changes from anxious to Immediate intervention is needed to prevent further
lethargic cerebral dysfunction.Deep furrows on the surface of
B. Deep furrows on the the tongue, poor skin turgor, and low urine output are
surface of the tongue all caused by the fluid volume deficit, but do not
C. Poor skin turgor with indicate complications of dehydration that are
tenting remaining for 2 immediately life-threatening.
minutes after the skin is
pinched
D. Urine output of 950 mL
for the past 24 hours
1/25
,8/14/25, 4:57 PM Fluid and Electrolytes NCLEX
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 Nursing actions indicated at this time include: placing
(ED) by her family. She the client on bedrest and assisting the client out of
states she has been taking bed, evaluating electrolyte levels, assessing for
her diuretics for orthostatic hypotension, and applying a cardiac
congestive heart failure monitor. Safety is required to prevent falls due to
(CHF). What nursing weakness from a likely fluid volume deficit and
actions are indicated at electrolyte imbalance. The nurse should review the
this time? laboratory and diagnostic results to detect likely loss
SELECT ALL THAT APPLY. of sodium, potassium, and magnesium secondary to
diarrhea and diuretic us. Fluid volume deficit is likely
A. Place the client on bed with diarrhea and diuretic use and leads to fluid and
rest. electrolyte imbalances, especially hypokalemia.
B. Evaluate the electrolyte Assessing for orthostatic changes will confirm
levels. presence of volume deficit. Monitoring for inverted T
C. Administer the ordered wave or presence of U wave on the ECG as well as
diuretic. dysrhythmias is indicated when hypokalemia is
D. Assess for orthostatic anticipated.Diuretics increase loss of fluids and
hypotension electrolytes. The nurse would question this order in
E. Initiate cardiac the presence of assessment data indicating fluid loss
monitoring. from the diuretics and diarrhea.
2/25
, 8/14/25, 4:57 PM Fluid and Electrolytes NCLEX
A, B, C
A client with hypokalemia
has a prescription for
RATIONALE:
parenteral potassium
Interventions to safely administer KCl to a client with
chloride (KCl). Which of
hypokalemia include: using a pharmacy prepared
these interventions does
potassium infusion, checking the client for any burning
the nurse use to safely
or redness during infusion, and infusing the IV at not
administer KCl?
more than 10 mEq per hour. The Joint Commission's
SELECT ALL THAT APPLY.
National Client Safety Goals mandates that
concentrated potassium be diluted and added to IV
A. Use a potassium
solutions only in the pharmacy by a registered
infusion prepared by a
pharmacist and that vials of concentrated potassium
registered pharmacist.
not be available in client care areas. IV potassium
B. Assess for burning or
solutions irritate veins and cause phlebitis. Assess the
redness during infusion.
IV site hourly, and ask the client whether he or she
C. Infuse at a rate of no
feels burning or pain at the site. The presence of pain
more than 10 mEq per
or burning at the insertion site may require a new
hour.
intravenous to be started. A dose of KCl 5-10
D. Administer only through
mEq/hour, no more than 20 mEq/hr is
a central venous catheter.
recommended.Potassium may be administered by
E. Administer by IV push
peripheral or central vein. There is no circumstance
only during cardiac arrest.
where potassium is given by IV push.
3/25
Fluid and Electrolytes NCLEX complete
questions and accurate detailed answers
verified 100% latest update 2025
The RN is assessing a 70- A. Client behavior that changes from anxious to
year-old client admitted lethargic
to the unit with severe
dehydration. Which finding RATIONALE:
requires immediate Immediate intervention by the nurse is required when
intervention by the nurse? a client's behavior changes from anxious to lethargic.
This change in mental status suggests poor cerebral
A. Client behavior that blood flow and fluid shifts within the brain cells.
changes from anxious to Immediate intervention is needed to prevent further
lethargic cerebral dysfunction.Deep furrows on the surface of
B. Deep furrows on the the tongue, poor skin turgor, and low urine output are
surface of the tongue all caused by the fluid volume deficit, but do not
C. Poor skin turgor with indicate complications of dehydration that are
tenting remaining for 2 immediately life-threatening.
minutes after the skin is
pinched
D. Urine output of 950 mL
for the past 24 hours
1/25
,8/14/25, 4:57 PM Fluid and Electrolytes NCLEX
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 Nursing actions indicated at this time include: placing
(ED) by her family. She the client on bedrest and assisting the client out of
states she has been taking bed, evaluating electrolyte levels, assessing for
her diuretics for orthostatic hypotension, and applying a cardiac
congestive heart failure monitor. Safety is required to prevent falls due to
(CHF). What nursing weakness from a likely fluid volume deficit and
actions are indicated at electrolyte imbalance. The nurse should review the
this time? laboratory and diagnostic results to detect likely loss
SELECT ALL THAT APPLY. of sodium, potassium, and magnesium secondary to
diarrhea and diuretic us. Fluid volume deficit is likely
A. Place the client on bed with diarrhea and diuretic use and leads to fluid and
rest. electrolyte imbalances, especially hypokalemia.
B. Evaluate the electrolyte Assessing for orthostatic changes will confirm
levels. presence of volume deficit. Monitoring for inverted T
C. Administer the ordered wave or presence of U wave on the ECG as well as
diuretic. dysrhythmias is indicated when hypokalemia is
D. Assess for orthostatic anticipated.Diuretics increase loss of fluids and
hypotension electrolytes. The nurse would question this order in
E. Initiate cardiac the presence of assessment data indicating fluid loss
monitoring. from the diuretics and diarrhea.
2/25
, 8/14/25, 4:57 PM Fluid and Electrolytes NCLEX
A, B, C
A client with hypokalemia
has a prescription for
RATIONALE:
parenteral potassium
Interventions to safely administer KCl to a client with
chloride (KCl). Which of
hypokalemia include: using a pharmacy prepared
these interventions does
potassium infusion, checking the client for any burning
the nurse use to safely
or redness during infusion, and infusing the IV at not
administer KCl?
more than 10 mEq per hour. The Joint Commission's
SELECT ALL THAT APPLY.
National Client Safety Goals mandates that
concentrated potassium be diluted and added to IV
A. Use a potassium
solutions only in the pharmacy by a registered
infusion prepared by a
pharmacist and that vials of concentrated potassium
registered pharmacist.
not be available in client care areas. IV potassium
B. Assess for burning or
solutions irritate veins and cause phlebitis. Assess the
redness during infusion.
IV site hourly, and ask the client whether he or she
C. Infuse at a rate of no
feels burning or pain at the site. The presence of pain
more than 10 mEq per
or burning at the insertion site may require a new
hour.
intravenous to be started. A dose of KCl 5-10
D. Administer only through
mEq/hour, no more than 20 mEq/hr is
a central venous catheter.
recommended.Potassium may be administered by
E. Administer by IV push
peripheral or central vein. There is no circumstance
only during cardiac arrest.
where potassium is given by IV push.
3/25
