Fluid and Electrolytes NCLEX Questions
1. The RN is assessing a A. Client behavior that changes from anxious to lethargic
70- year-old client admitted
to the unit with severe de- RATIONALE:
hydration. Which finding re- Immediate intervention by the nurse is required when a client's
quires immediate interven- behavior changes from anxious to lethargic. This change in men-
tion by the nurse? tal status suggests poor cerebral blood flow and fluid shifts with-
in the brain cells. Immediate intervention is needed to prevent
A. Client behavior that further cerebral dysfunction.Deep furrows on the surface of the
changes from anxious to tongue, poor skin turgor, and low urine output are all caused
lethargic by the fluid volume deficit, but do not indicate complications of
B. Deep furrows on the sur- dehydration that are immediately life-threatening.
face of the tongue
C. Poor skin turgor with tent-
ing remaining for 2 minutes
after the skin is pinched
D. Urine output of 950 mL for
the past 24 hours
2. 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 (ED) Nursing actions indicated at this time include: placing the client
by her family. She states she on bedrest and assisting the client out of bed, evaluating elec-
has been taking her diuretics trolyte levels, assessing for orthostatic hypotension, and apply-
for congestive heart failure ing a cardiac monitor. Safety is required to prevent falls due
(CHF). What nursing actions to weakness from a likely fluid volume deficit and electrolyte
are indicated at this time? imbalance. The nurse should review the laboratory and diag-
SELECT ALL THAT APPLY. nostic results to detect likely loss of sodium, potassium, and
magnesium secondary to diarrhea and diuretic us. Fluid volume
A. Place the client on bed deficit is likely with diarrhea and diuretic use and leads to fluid
rest. and electrolyte imbalances, especially hypokalemia. Assessing
B. Evaluate the electrolyte for orthostatic changes will confirm presence of volume deficit.
, Fluid and Electrolytes NCLEX Questions
levels. Monitoring for inverted T wave or presence of U wave on the
C. Administer the ordered di- ECG as well as dysrhythmias is indicated when hypokalemia is
uretic. anticipated.Diuretics increase loss of fluids and electrolytes. The
D. Assess for orthostatic hy- nurse would question this order in the presence of assessment
potension data indicating fluid loss from the diuretics and diarrhea.
E. Initiate cardiac monitoring.
3. A client with hypokalemia has A, B, C
a prescription for parenter-
al potassium chloride (KCl). RATIONALE:
Which of these interventions Interventions to safely administer KCl to a client with hypokalemia
does the nurse use to safely include: using a pharmacy prepared potassium infusion, check-
administer KCl? ing the client for any burning or redness during infusion, and
SELECT ALL THAT APPLY. infusing the IV at not more than 10 mEq per hour. The Joint
Commission's National Client Safety Goals mandates that con-
A. Use a potassium infu- centrated potassium be diluted and added to IV solutions only
sion prepared by a registered in the pharmacy by a registered pharmacist and that vials of
pharmacist. concentrated potassium not be available in client care areas.
B. Assess for burning or red- IV potassium solutions irritate veins and cause phlebitis. Assess
ness during infusion. the IV site hourly, and ask the client whether he or she feels
C. Infuse at a rate of no more burning or pain at the site. The presence of pain or burning at the
than 10 mEq per hour. insertion site may require a new intravenous to be started. A dose
D. Administer only through a of KCl 5-10 mEq/hour, no more than 20 mEq/hr is recommend-
central venous catheter. ed.Potassium may be administered by peripheral or central vein.
E. Administer by IV push only There is no circumstance where potassium is given by IV push.
during cardiac arrest.
4. The nurse is caring for a client A, B, D
who is receiving a loop diuret-
ic for treatment of heart fail- RATIONALE:
ure. Which of these actions Actions for the nurse to include when caring for a client taking a
will be included in the plan of loop diuretic for heart failure include: assessing daily weights,
, Fluid and Electrolytes NCLEX Questions
care? encouraging consumption of citrus fruits, and monitoring the
SELECT ALL THAT APPLY. client's serum potassium. High-ceiling (loop) diuretics remove
A. Assess daily weights. excess fluid and are potassium-depleting drugs. Consuming cit-
B. Encourage consumption of rus fruit, green leafy vegetables, cantaloupe, tomato, and other
citrus fruits. food with potassium is indicated while receiving this type of
C. Weigh the client weekly. diuretic to compensate for urinary loss of potassium.The client
D. Monitor serum potassi- must be weighed at the same time each day, using the same
um. scale and wearing approximately the same amount of clothes.
E. Discourage intake of Green leafy vegetables such as spinach contain potassium and
spinach. are encouraged. The diuretic itself has no ettect on the heart rate,
F. Monitor for bradycardia. however potassium depletion caused by the diuretic may cause
cardiac irritability with a weak and thready pulse.
5. The nurse is caring for a client A. Heart rate
who takes furosemide (Lasix)
and digoxin (Lanoxin). The RATIONALE:
client's potassium (K+) level The nurse must assess the heart rate for bradycardia related to
is 2.5 mEq/L (2.5 mmol/L). digoxin and irritability or irregularity related to hypokalemia. Hy-
Which additional assessment pokalemia increases the sensitivity of cardiac muscle to digoxin
will the nurse make? and may result in digoxin toxicity, even when the digoxin level
A. Heart rate is within the therapeutic range. The nurse also assesses for GI
B. Blood pressure (BP) symptoms such as diarrhea, and other symptoms of toxicity to
C. Increases in edema digoxin.The BP may decrease with low potassium level but mon-
D. Sodium level itoring 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.
6. Furosemide (Lasix) has been C. The client is free from adventitious breath sounds.
ordered for a client with heart
failure, shortness of breath, RATIONALE:
and 3+ pitting edema of the The nurse recognizes that Furosemide is ettective when the
1. The RN is assessing a A. Client behavior that changes from anxious to lethargic
70- year-old client admitted
to the unit with severe de- RATIONALE:
hydration. Which finding re- Immediate intervention by the nurse is required when a client's
quires immediate interven- behavior changes from anxious to lethargic. This change in men-
tion by the nurse? tal status suggests poor cerebral blood flow and fluid shifts with-
in the brain cells. Immediate intervention is needed to prevent
A. Client behavior that further cerebral dysfunction.Deep furrows on the surface of the
changes from anxious to tongue, poor skin turgor, and low urine output are all caused
lethargic by the fluid volume deficit, but do not indicate complications of
B. Deep furrows on the sur- dehydration that are immediately life-threatening.
face of the tongue
C. Poor skin turgor with tent-
ing remaining for 2 minutes
after the skin is pinched
D. Urine output of 950 mL for
the past 24 hours
2. 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 (ED) Nursing actions indicated at this time include: placing the client
by her family. She states she on bedrest and assisting the client out of bed, evaluating elec-
has been taking her diuretics trolyte levels, assessing for orthostatic hypotension, and apply-
for congestive heart failure ing a cardiac monitor. Safety is required to prevent falls due
(CHF). What nursing actions to weakness from a likely fluid volume deficit and electrolyte
are indicated at this time? imbalance. The nurse should review the laboratory and diag-
SELECT ALL THAT APPLY. nostic results to detect likely loss of sodium, potassium, and
magnesium secondary to diarrhea and diuretic us. Fluid volume
A. Place the client on bed deficit is likely with diarrhea and diuretic use and leads to fluid
rest. and electrolyte imbalances, especially hypokalemia. Assessing
B. Evaluate the electrolyte for orthostatic changes will confirm presence of volume deficit.
, Fluid and Electrolytes NCLEX Questions
levels. Monitoring for inverted T wave or presence of U wave on the
C. Administer the ordered di- ECG as well as dysrhythmias is indicated when hypokalemia is
uretic. anticipated.Diuretics increase loss of fluids and electrolytes. The
D. Assess for orthostatic hy- nurse would question this order in the presence of assessment
potension data indicating fluid loss from the diuretics and diarrhea.
E. Initiate cardiac monitoring.
3. A client with hypokalemia has A, B, C
a prescription for parenter-
al potassium chloride (KCl). RATIONALE:
Which of these interventions Interventions to safely administer KCl to a client with hypokalemia
does the nurse use to safely include: using a pharmacy prepared potassium infusion, check-
administer KCl? ing the client for any burning or redness during infusion, and
SELECT ALL THAT APPLY. infusing the IV at not more than 10 mEq per hour. The Joint
Commission's National Client Safety Goals mandates that con-
A. Use a potassium infu- centrated potassium be diluted and added to IV solutions only
sion prepared by a registered in the pharmacy by a registered pharmacist and that vials of
pharmacist. concentrated potassium not be available in client care areas.
B. Assess for burning or red- IV potassium solutions irritate veins and cause phlebitis. Assess
ness during infusion. the IV site hourly, and ask the client whether he or she feels
C. Infuse at a rate of no more burning or pain at the site. The presence of pain or burning at the
than 10 mEq per hour. insertion site may require a new intravenous to be started. A dose
D. Administer only through a of KCl 5-10 mEq/hour, no more than 20 mEq/hr is recommend-
central venous catheter. ed.Potassium may be administered by peripheral or central vein.
E. Administer by IV push only There is no circumstance where potassium is given by IV push.
during cardiac arrest.
4. The nurse is caring for a client A, B, D
who is receiving a loop diuret-
ic for treatment of heart fail- RATIONALE:
ure. Which of these actions Actions for the nurse to include when caring for a client taking a
will be included in the plan of loop diuretic for heart failure include: assessing daily weights,
, Fluid and Electrolytes NCLEX Questions
care? encouraging consumption of citrus fruits, and monitoring the
SELECT ALL THAT APPLY. client's serum potassium. High-ceiling (loop) diuretics remove
A. Assess daily weights. excess fluid and are potassium-depleting drugs. Consuming cit-
B. Encourage consumption of rus fruit, green leafy vegetables, cantaloupe, tomato, and other
citrus fruits. food with potassium is indicated while receiving this type of
C. Weigh the client weekly. diuretic to compensate for urinary loss of potassium.The client
D. Monitor serum potassi- must be weighed at the same time each day, using the same
um. scale and wearing approximately the same amount of clothes.
E. Discourage intake of Green leafy vegetables such as spinach contain potassium and
spinach. are encouraged. The diuretic itself has no ettect on the heart rate,
F. Monitor for bradycardia. however potassium depletion caused by the diuretic may cause
cardiac irritability with a weak and thready pulse.
5. The nurse is caring for a client A. Heart rate
who takes furosemide (Lasix)
and digoxin (Lanoxin). The RATIONALE:
client's potassium (K+) level The nurse must assess the heart rate for bradycardia related to
is 2.5 mEq/L (2.5 mmol/L). digoxin and irritability or irregularity related to hypokalemia. Hy-
Which additional assessment pokalemia increases the sensitivity of cardiac muscle to digoxin
will the nurse make? and may result in digoxin toxicity, even when the digoxin level
A. Heart rate is within the therapeutic range. The nurse also assesses for GI
B. Blood pressure (BP) symptoms such as diarrhea, and other symptoms of toxicity to
C. Increases in edema digoxin.The BP may decrease with low potassium level but mon-
D. Sodium level itoring 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.
6. Furosemide (Lasix) has been C. The client is free from adventitious breath sounds.
ordered for a client with heart
failure, shortness of breath, RATIONALE:
and 3+ pitting edema of the The nurse recognizes that Furosemide is ettective when the
