NCLEX Fluid and Electrolytes 851 QUESTIONS & ANSWERS
2022/2023
Terms in this set (851)
Answer: 1
What is the nurse's primary concern Rationale 1: As
... [Show More] an adult ages, the thirst mechanism
regarding fluid & electrolytes when declines. Adding this in a pt with an altered level of
caring for an elderly pt who is consciousness, there is an increased risk of dehydration &
intermittently confused? high serum osmolality.
1. risk of dehydration Rationale 2: The risks for kidney damage are not
2. risk of kidney damage specifically related to aging or fluid & electrolyte issues.
3. risk of stroke Rationale 3: The risk of stroke is not specifically related to
4. risk of bleeding aging or fluid & electrolyte issues.
Rationale 4: The risk of bleeding is not specifically related
to aging or fluid & electrolyte issues.
NCLEX Fluid and Electrolytes Study
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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
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 Answer: 1
excessive thirst, increased
NCLEX Fluid and Electrolytes Study
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
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 Answer: 1
an indwelling urinary catheter. The Rationale 1: A urine output of less than 30 mL per hour
nurse would contact the pt's must be reported to the primary healthcare provider. This
primary healthcare provider with indicates inadequate renal perfusion, placing the pt at
which of the following 24-hour increased risk for acute renal failure & inadequate tissue
urine output volumes? perfusion. A minimum of 720 mL over a 24-hour period is
1. 600 mL desired (30 mL multiplied by 24 hours equals 720 mL per
2. 750 mL 24 hours).
3. 1000 mL
4. 1200 mL
Answer: 1
Rationale 1: Antidiuretic hormone & aldosterone levels are
A pt is receiving intravenous fluids
commonly increased following the stress response
postoperatively following cardiac
before, during, & immediately after surgery. This increase
surgery. Nursing assessments
leads to sodium & water retention. Adding more fluids
should focus on which
intravenously can cause a fluid volume excess & stress
postoperative complication?
upon the heart & circulatory system.
1. fluid volume excess
Rationale 2: Adding more fluids intravenously can cause a
2. fluid volume deficit
fluid volume excess, not fluid volume deficit, & stress
3. seizure activity
upon the heart & circulatory system.
4. liver failure
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.
Answer: 1
Rationale 1: Severe hyponatremia can lead to seizures.
NCLEX Fluid and Electrolytes Study
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
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
Answer: 1
hypokalemia. After reviewing the
Rationale 1: Excess potassium loss through the kidneys is
pt's current medications, which of
often caused by such meds as corticosteroids, potassiumthe following might have
wasting diuretics, amphotericin B, & large doses of some
contributed to the pt's health
antibiotics.
problem?
Rationale 2: Excessive sodium is lost with the use of
1. corticosteroid
thiazide diuretics.
2. thiazide diuretic
Rationale 3: Narcotics do not typically affect electrolyte
3.
narcotic
balance.
4. muscle relaxer
Rationale 4: Muscle relaxants do not typically affect
electrolyte balance.
Answer: 1
A pt prescribed spironolactone is
Rationale 1: Hyperkalemia is serum potassium level greater
demonstrating ECG changes &
than 5.0 mEq/L. Decreased potassium excretion is seen in
complaining of muscle weakness.
potassium-sparing diuretics such as spironolactone.
The nurse realizes this pt is
Common manifestations of hyperkalemia are muscle
exhibiting signs of which of the
weakness & ECG changes.
following?
Rationale 2: Hypokalemia is seen in non-potassium
1. hyperkalemia
diuretics such as furosemide.
2. hypokalemia
Rationale 3: Hypercalcemia has been associated with
3. hypercalcemia
thiazide diuretics.
4. hypocalcemia
Rationale 4: Hypocalcemia is seen in pts who have
received many units of citrated blood & is not associated
with diuretic use.
Answer: 1
The nurse is planning care for a pt Rationale 1: The nursing care for a pt with hyponatremia is
NCLEX Fluid and Electrolytes Study
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.
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.
When caring for a pt diagnosed
Answer: 1
with hypocalcemia, which of the
Rationale 1: The pt diagnosed with hypocalcemia may also
following should the nurse
have high phosphorus or decreased magnesium levels.
additionally assess in the pt?
Rationale 2: The pt with hypocalcemia may exhibit
1. other electrolyte disturbances
hypotension, & not hypertension.
2.
hypertension
Rationale 3: Visual disturbances do not occur with
3. visual disturbances
hypocalcemia.
4.
drug toxicity
Rationale 4: Hypercalcemia is more commonly caused by
drug toxicities.
A pt with a history of stomach Answer: 1
ulcers is diagnosed with Rationale 1: Treatment of hypophosphatemia includes
hypophosphatemia. Which of the treating the underlying cause & promoting a high
following interventions should the phosphate diet, especially milk, if it is tolerated. Other
nurse include in this pt's plan of foods high in phosphate are dried beans & peas, eggs,
care? fish, organ meats, Brazil nuts & peanuts, poultry, seeds &
1. Request a dietitian consult for whole grains.
selecting foods high in Rationale 2: Phosphate-binding antacids, such as
phosphorous. aluminum hydroxide, should be avoided.
2. Provide aluminum hydroxide Rationale 3: Poultry, peanuts, & seeds are part of a high
antacids as prescribed. phosphate diet.
3. Instruct pt to avoid poultry, Rationale 4: Mild hypophosphatemia may be corrected by
peanuts, & seeds. oral supplements, such as sodium phosphate.
4. Instruct to avoid the intake of
sodium phosphate.
When analyzing an arterial blood Answer: 1
gas report of a pt with COPD & Rationale 1: The kidneys will compensate for a respiratory
NCLEX Fluid and Electrolytes Study
respiratory acidosis, the nurse
anticipates that compensation will
develop through which of the
following mechanisms?
1. The kidneys retain bicarbonate.
2. The kidneys excrete bicarbonate.
3. The lungs will retain carbon
dioxide.
4. The lungs will excrete carbon
dioxide.
disorder by retaining bicarbonate.
Rationale 2: Excreting bicarbonate causes acidosis to
develop.
Rationale 3: Retaining carbon dioxide causes respiratory
acidosis.
Rationale 4: Excreting carbon dioxide causes respiratory
alkalosis
The nurse is caring for a pt
Answer: 1
diagnosed with renal failure. Which
Rationale 1: In metabolic acidosis compensation is
of the following does the nurse
accomplished through increased ventilation or "blowing
recognize as compensation for the
off" C02. This raises the pH by eliminating the volatile
acid-base disturbance found in pts
respiratory acid & compensates for the acidosis.
with renal failure?
Rationale 2: Because compensation must be performed
1. The pt breathes rapidly to
by the system other than the affected system, the pt
eliminate carbon dioxide.
cannot retain bicarbonate; the manifestation of metabolic
2. The pt will retain bicarbonate in
acidosis of renal failure is a lower than normal bicarbonate
excess of normal.
value.
3. The pH will decrease from the
Rationale 3: Metabolic acidosis of renal failure causes a
present value.
low pH; this is the manifestation of the disease process,
4.
The pt's oxygen saturation level
not the compensation.
will improve.
Rationale 4: Oxygenation disturbance is not part of the
acid-base status of the pt with renal failure.
Answer: 1
Rationale 1: Metabolic alkalosis is cause by vomiting,
NCLEX Fluid and Electrolytes Study
When caring for a group of pts, the
nurse realizes that which of the
following health problems
increases the risk for metabolic
alkalosis?
1. bulimia
2. dialysis
3. venous stasis ulcer
4. COPD
diuretic therapy or nasogastric suction, among others. A
pt with bulimia may engage in vomiting or indiscriminate
use of diuretics.
Rationale 2: A pt receiving dialysis has kidney failure,
which causes metabolic acidosis.
Rationale 3: A venous stasis ulcer does not result in an
acid-base disorder.
Rationale 4: The pt diagnosed with COPD typically has
hypercapnea & respiratory acidosis.
The nurse is caring for a pt who is Answer: 1
anxious & dizzy following a Rationale 1: This pt is exhibiting signs of hyperventilation
traumatic experience. The arterial that is confirmed with the blood gas results of respiratory
blood gas findings include: pH alkalosis. Breathing into a paper bag will help the pt to
7.48, PaO2 110, PaCO2 25, & HCO3 retain carbon dioxide & lower oxygen levels to normal,
24. The nurse would anticipate correcting the cause of the problem.
which initial intervention to correct Rationale 2: The oxygen levels are high, so oxygen is not
this problem? indicated, & would exacerbate the problem if given.
1. Encourage the pt to breathe in & Intravenous fluids would not be the initial intervention.
out slowly into a paper bag. Rationale 3: Not enough information is given to determine
2. Immediately administer oxygen the need for intravenous fluids.
via a mask & monitor oxygen Rationale 4: Bicarbonate would be contraindicated as the
saturation. pH is already high.
3. Prepare to start an intravenous
fluid bolus using isotonic fluids.
4. Anticipate the administration of
intravenous sodium bicarbonate.
Answer: 2
Rationale 1: Potassium does not sustain respiratory
NCLEX Fluid and Electrolytes Study
A pt is prescribed 20 mEq of
potassium chloride. The nurse
realizes that the reason the pt is
receiving this replacement is
1. to sustain respiratory function.
2. to help regulate acid-base
balance.
3. to keep a vein open.
4. to encourage urine output.
function.
Rationale 2: Electrolytes have many functions. They assist
in regulating water balance, help regulate & maintain acidbase balance, contribute to enzyme reactions, & are
essential for neuromuscular activity.
Rationale 3: Intravenous fluids are used to keep venous
access not potassium.
Rationale 4: Urinary output is impacted by fluid intake not
potassium.
An elderly pt does not complain of Answer: 3
thirst. What should the nurse do to Rationale 1: It is inappropriate to seek an IV at this stage.
assess that this pt is not Rationale 2: There is no indication the pt is experiencing
dehydrated? pulmonary complications thus a cheat x-ray is not
1. Ask the physician for an order to indicated.
begin intravenous fluid Rationale 3: The thirst mechanism declines with aging,
replacement. which makes older adults more vulnerable to dehydration
2. Ask the physician to order a & hyperosmolality. The nurse should check the pt's urine
chest x-ray. for osmolality as a 1st step in determining hydration status
3. Assess the urine for osmolality. before other detailed & invasive testing is done.
4. Ask the physician for an order for Rationale 4: There is no data to support the need for a
a brain scan. brain scan.
Correct Answer: 1
Rationale 1: Functional changes of aging also affect fluid
An elderly pt who is being balance. Older adults who have self-care deficits, or who
medicated for pain had an episode are confused, depressed, tube-fed, on bed rest, or taking
of incontinence. The nurse realizes medications (such as sedatives, tranquilizers, diuretics, &
that this pt is at risk for developing laxatives), are at greatest risk for fluid volume imbalance.
1. dehydration. Rationale 2: There is inadequate evidence to support the
2. over-hydration. risk of over-hydration.
3. fecal incontinence. Rationale 3: There is inadequate evidence to support the
4. a stroke. risk of fecal incontinence.
Rationale 4: There is inadequate evidence to support the
risk of a stroke.
The nurse assesses a pt's weight Correct Answer: 10
loss as being 22 lbs. How many Rationale: Each liter of body fluid weighs 1 kg or 2.2 lbs.
NCLEX Fluid and Electrolytes Study
liters of fluid did this pt lose? This pt has lost 10 liters of fluid.
A postoperative pt with a fluid Answer: 3
volume deficit is prescribed Rationale 1: The pt should avoid prolonged standing.
progressive ambulation yet is weak Rationale 2 [Show Less]