Healthcare Facility Types and Patient Care Concepts for Nursing
Assistants,Nclex style questions fluids and electrolytes & Maternal - Post-
Partum Exam Cummulated examination tests 2025 QUESTIONS WITH
CORRECT ANSWERS VERIFIED 100% GRADED A+
Nclex style questions fluids and electrolytes
The nurse is obtaining the intershift report for a group of assigned clients.
Which assigned client should the nurse monitor closely for signs of
hyperkalemia?
1.A client with ulcerative colitis 2.A client with Cushing's syndrome 3.A client
admitted 6 hours ago with a 40% burn injury 4.A client who has a history of
long-term laxative abuse
A client admitted 6 hours ago with a 40% burn injury
Rationale: Hyperkalemia is likely to occur in clients who experience cellular shifting
of potassium caused by early massive cell destruction, such as in trauma or burns.
Other clients at risk for hyperkalemia are those with sepsis or metabolic or
respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's
syndrome or ulcerative colitis or those using laxatives excessively are at risk for
hypokalemia.
Which clients are most likely to be at risk for the development of third
spacing? Select all that apply.
1.The client with cirrhosis 2.The client with liver failure 3.The client with
diabetes mellitus 4.The client with a minor burn injury 5.The client with chronic
kidney disease
1.The client with cirrhosis 2.The client with liver failure 5.The client with chronic
kidney disease
Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to
as third-space fluid. Common sites for third spacing include the abdomen, pleural
cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically
useless because it does not circulate to provide nutrients for the cells. Risk factors
,for third spacing include clients with liver or kidney disease, major trauma, burns,
sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption,
malnutrition, and alcoholic or older adult clients.
The nurse is reading a primary health care provider's (PHCP's) progress notes
in the client's record and reads that the PHCP has documented "insensible
fluid loss of approximately 800 mL daily." The nurse makes a notation that
insensible fluid loss occurs through which type of excretion?
1.Urinary output 2.Wound drainage 3.Integumentary output 4.The
gastrointestinal tract
3.Integumentary output
Rationale: Insensible losses may occur without the person's awareness. Insensible
losses occur daily through the skin and the lungs. Sensible losses are those of which
the person is aware, such as through urination, wound drainage, and gastrointestinal
tract losses.
The nurse is caring for a group of clients on the clinical nursing unit. Which
client should the nurse plan to monitor for signs of fluid volume deficit?
1.Client in heart failure 2.Client in acute kidney injury 3.Client with diabetes
insipidus 4.Client with controlled hypertension
3.Client with diabetes insipidus
Rationale: The client with an ileostomy is at risk for fluid volume deficit caused by
increased gastrointestinal tract losses. Other causes of fluid volume deficit include
vomiting, diarrhea, conditions that cause increased respiratory rate or urine output
such as diabetes insipidus, insufficient intravenous fluid replacement, draining
fistulas, and the presence of an ileostomy or colostomy. Clients who have heart
failure or kidney disease are at risk for fluid volume excess. Hypertension may be
associated with fluid volume excess.
The nurse reviews a client's record and determines that the client is at risk for
developing a potassium deficit if which situation is documented?
1.Sustained tissue damage 2.Requires nasogastric suction 3.Has a history of
Addison's disease 4.Uric acid level of 9.4 mg/dL (557 mcmol/L)
2.Requires nasogastric suction
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0
mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich
gastrointestinal fluids are lost through gastrointestinal suction, placing the client at
,risk for hypokalemia. The client with tissue damage or Addison's disease and the
client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a
female is 2.7 to 7.3 mg/dL (160 to 430 mcmol/L) and for a male is 4.0 to 8.5 mg/dL
(240 to 501 mcmol/L).
The nurse has a prescription to hang a crystalloid intravenous solution of
lactated Ringer's on a newly admitted client. The nurse notices that the client
has a history of alcoholic cirrhosis. What action should the nurse take first?
1.Hang the solution. 2.Contact the primary health care provider
(PHCP). 3.Check the client's daily laboratory results. 4.Ask the client if any
liver study tests have ever been done.
2.Contact the primary health care provider (PHCP).
Rationale: The nurse must contact the PHCP before administering the solution.
Fluid and electrolyte replacement solutions like lactated Ringer's are contraindicated
for clients with kidney and liver disease or lactic acidosis.
The nurse is reviewing the laboratory results for a client who is receiving
magnesium sulfate by intravenous infusion. The nurse notes that the
magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory
result, the nurse should expect to note which in the client?
1.Tremors 2.Hyperactive reflexes 3.Respiratory depression 4.No specific signs
or symptoms because this value is a normal level
3.Respiratory depression
Rationale: The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L).
Neurological depression occurs in hypermagnesemia and is manifested by
drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and
areflexia.
The nurse is reviewing a client's laboratory report and notes that the total
serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that
which condition most likely caused this serum calcium level?
1.Prolonged bed rest 2.Renal insufficiency 3.Hyperparathyroidism 4.Excessive
ingestion of vitamin D
1.Prolonged bed rest
Rationale: The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75
mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is
experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia.
, Although immobilization initially can cause hypercalcemia, the long-term effect of
prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal
insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive
ingestion of vitamin D are causative factors associated with hypercalcemia.
The nurse reviews the electrolyte results of an assigned client and notes that
the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse
watch for on the cardiac monitor as a result of the laboratory value? Select all
that apply.
1.ST depression 2.Prominent U wave 3.Tall peaked T waves 4.Prolonged ST
segment 5.Widened QRS complexes
3.Tall peaked T waves 5.Widened QRS complexes
Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A
serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia.
Electrocardiographic changes associated with hyperkalemia include flat P waves,
prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST
depression and a prominent U wave occurs in hypokalemia. A prolonged ST
segment occurs in hypocalcemia.
The nurse who is caring for a client with severe malnutrition reviews the
laboratory results and notes that the client has a magnesium level of 1.0
mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse
expect to observe based on the client's magnesium level?
1.Prominent U waves 2.Prolonged PR interval 3.Depressed ST
segment 4.Widened QRS complexes
3.Depressed ST segment
Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05
mmol/L). A magnesium level of 1.0 mEq/L (0.5 mmol/L) indicates hypomagnesemia.
In hypomagnesemia, tall T waves and a depressed ST segment would be observed.
Options 2 and 4 would be noted in a client experiencing hypermagnesemia.
Prominent U waves occur with hypokalemia.
The nurse is calculating a client's fluid intake for a 24-hour period. The client is
on hemodialysis and urinates about 100 mL a day. The client is on a fluid
restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange
juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his
medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at
Assistants,Nclex style questions fluids and electrolytes & Maternal - Post-
Partum Exam Cummulated examination tests 2025 QUESTIONS WITH
CORRECT ANSWERS VERIFIED 100% GRADED A+
Nclex style questions fluids and electrolytes
The nurse is obtaining the intershift report for a group of assigned clients.
Which assigned client should the nurse monitor closely for signs of
hyperkalemia?
1.A client with ulcerative colitis 2.A client with Cushing's syndrome 3.A client
admitted 6 hours ago with a 40% burn injury 4.A client who has a history of
long-term laxative abuse
A client admitted 6 hours ago with a 40% burn injury
Rationale: Hyperkalemia is likely to occur in clients who experience cellular shifting
of potassium caused by early massive cell destruction, such as in trauma or burns.
Other clients at risk for hyperkalemia are those with sepsis or metabolic or
respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's
syndrome or ulcerative colitis or those using laxatives excessively are at risk for
hypokalemia.
Which clients are most likely to be at risk for the development of third
spacing? Select all that apply.
1.The client with cirrhosis 2.The client with liver failure 3.The client with
diabetes mellitus 4.The client with a minor burn injury 5.The client with chronic
kidney disease
1.The client with cirrhosis 2.The client with liver failure 5.The client with chronic
kidney disease
Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to
as third-space fluid. Common sites for third spacing include the abdomen, pleural
cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically
useless because it does not circulate to provide nutrients for the cells. Risk factors
,for third spacing include clients with liver or kidney disease, major trauma, burns,
sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption,
malnutrition, and alcoholic or older adult clients.
The nurse is reading a primary health care provider's (PHCP's) progress notes
in the client's record and reads that the PHCP has documented "insensible
fluid loss of approximately 800 mL daily." The nurse makes a notation that
insensible fluid loss occurs through which type of excretion?
1.Urinary output 2.Wound drainage 3.Integumentary output 4.The
gastrointestinal tract
3.Integumentary output
Rationale: Insensible losses may occur without the person's awareness. Insensible
losses occur daily through the skin and the lungs. Sensible losses are those of which
the person is aware, such as through urination, wound drainage, and gastrointestinal
tract losses.
The nurse is caring for a group of clients on the clinical nursing unit. Which
client should the nurse plan to monitor for signs of fluid volume deficit?
1.Client in heart failure 2.Client in acute kidney injury 3.Client with diabetes
insipidus 4.Client with controlled hypertension
3.Client with diabetes insipidus
Rationale: The client with an ileostomy is at risk for fluid volume deficit caused by
increased gastrointestinal tract losses. Other causes of fluid volume deficit include
vomiting, diarrhea, conditions that cause increased respiratory rate or urine output
such as diabetes insipidus, insufficient intravenous fluid replacement, draining
fistulas, and the presence of an ileostomy or colostomy. Clients who have heart
failure or kidney disease are at risk for fluid volume excess. Hypertension may be
associated with fluid volume excess.
The nurse reviews a client's record and determines that the client is at risk for
developing a potassium deficit if which situation is documented?
1.Sustained tissue damage 2.Requires nasogastric suction 3.Has a history of
Addison's disease 4.Uric acid level of 9.4 mg/dL (557 mcmol/L)
2.Requires nasogastric suction
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0
mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich
gastrointestinal fluids are lost through gastrointestinal suction, placing the client at
,risk for hypokalemia. The client with tissue damage or Addison's disease and the
client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a
female is 2.7 to 7.3 mg/dL (160 to 430 mcmol/L) and for a male is 4.0 to 8.5 mg/dL
(240 to 501 mcmol/L).
The nurse has a prescription to hang a crystalloid intravenous solution of
lactated Ringer's on a newly admitted client. The nurse notices that the client
has a history of alcoholic cirrhosis. What action should the nurse take first?
1.Hang the solution. 2.Contact the primary health care provider
(PHCP). 3.Check the client's daily laboratory results. 4.Ask the client if any
liver study tests have ever been done.
2.Contact the primary health care provider (PHCP).
Rationale: The nurse must contact the PHCP before administering the solution.
Fluid and electrolyte replacement solutions like lactated Ringer's are contraindicated
for clients with kidney and liver disease or lactic acidosis.
The nurse is reviewing the laboratory results for a client who is receiving
magnesium sulfate by intravenous infusion. The nurse notes that the
magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory
result, the nurse should expect to note which in the client?
1.Tremors 2.Hyperactive reflexes 3.Respiratory depression 4.No specific signs
or symptoms because this value is a normal level
3.Respiratory depression
Rationale: The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L).
Neurological depression occurs in hypermagnesemia and is manifested by
drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and
areflexia.
The nurse is reviewing a client's laboratory report and notes that the total
serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that
which condition most likely caused this serum calcium level?
1.Prolonged bed rest 2.Renal insufficiency 3.Hyperparathyroidism 4.Excessive
ingestion of vitamin D
1.Prolonged bed rest
Rationale: The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75
mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is
experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia.
, Although immobilization initially can cause hypercalcemia, the long-term effect of
prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal
insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive
ingestion of vitamin D are causative factors associated with hypercalcemia.
The nurse reviews the electrolyte results of an assigned client and notes that
the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse
watch for on the cardiac monitor as a result of the laboratory value? Select all
that apply.
1.ST depression 2.Prominent U wave 3.Tall peaked T waves 4.Prolonged ST
segment 5.Widened QRS complexes
3.Tall peaked T waves 5.Widened QRS complexes
Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A
serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia.
Electrocardiographic changes associated with hyperkalemia include flat P waves,
prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST
depression and a prominent U wave occurs in hypokalemia. A prolonged ST
segment occurs in hypocalcemia.
The nurse who is caring for a client with severe malnutrition reviews the
laboratory results and notes that the client has a magnesium level of 1.0
mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse
expect to observe based on the client's magnesium level?
1.Prominent U waves 2.Prolonged PR interval 3.Depressed ST
segment 4.Widened QRS complexes
3.Depressed ST segment
Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05
mmol/L). A magnesium level of 1.0 mEq/L (0.5 mmol/L) indicates hypomagnesemia.
In hypomagnesemia, tall T waves and a depressed ST segment would be observed.
Options 2 and 4 would be noted in a client experiencing hypermagnesemia.
Prominent U waves occur with hypokalemia.
The nurse is calculating a client's fluid intake for a 24-hour period. The client is
on hemodialysis and urinates about 100 mL a day. The client is on a fluid
restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange
juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his
medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at
