Fluid and Electrolytes NCLEX questions

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The nurse obtains all of the following assessment data about
a patient with deficient fluid volume caused by a massive burn
injury. Which of the following assessment data will be of greatest
concern?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 ml over the last hour.
c. Oral fluid intake is 100 ml for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
A recently admitted patient has a small cell carcinoma of the
lung, which is causing the syndrome of inappropriate antidiuretic
hormone (SIADH). The nurse will monitor carefully for
a. increased total urinary output.
b. elevation of serum hematocrit.
c. decreased serum sodium level.
a. The blood pressure is 90/40 mm Hg.
The blood pressure indicates that the patient may be developing
hypovolemic shock as a result of fluid loss. This will require im-
mediate intervention to prevent the complications associated with
systemic hypoperfusion. The poor oral intake, decreased urine
output, and skin tenting all indicate the need for increasing the
patients fluid intake but not as urgently as the hypotension.
c. decreased serum sodium level.
SIADH causes water retention and a decrease in serum sodium
level. Weight loss, increased urine output, and elevated serum
hematocrit may be associated with excessive loss of water, but
not with SIADH and water retention.

d. rapid and unexpected weight loss.

When the nurse is evaluating the fluid balance for a patient ad-
mitted for hypovolemia associated with multiple draining wounds, b. daily weight.
the most accurate assessment to include is
Daily weight is the most easily obtained and accurate means of
a. skin turgor. assessing volume status. Skin turgor varies considerably with age.
Considerable excess fluid volume may be present before fluid
b. daily weight. moves into the interstitial space and causes edema. Hourly urine
outputs do not take account of fluid intake or of fluid loss through
c. presence of edema. insensible loss, sweating, or loss from the gastrointestinal tract or
wounds.
d. hourly urine output.
When caring for an alert and oriented elderly patient with a history
of dehydration, the home health nurse will teach the patient to b. if the oral mucosa feels dry.
increase fluid intake
An alert, elderly patient will be able to self-assess for signs of oral
a. in the late evening hours. dryness such as thick oral secretions or dry-appearing mucosa.
The thirst mechanism decreases with age and is not an accurate
b. if the oral mucosa feels dry. indicator of volume depletion. Many older patients prefer to restrict
fluids slightly in the evening to improve sleep quality. The patient
c. when the patient feels thirsty. will not be likely to notice and act appropriately when changes in
LOC occur.
d. as soon as changes in level of consciousness (LOC) occur.
A patient is taking a potassium-wasting diuretic for treatment of
hypertension. The nurse will teach the patient to report symptoms
d. generalized weakness.
of adverse effects such as
Generalized weakness progressing to flaccidity is a manifestation
a. personality changes.
of hypokalemia. Facial muscle spasms might occur with hypocal-
cemia. Loose stools are associated with hyperkalemia. Person-
b. frequent loose stools.
ality changes are not associated with electrolyte disturbances,
although changes in mental status are common manifestations
c. facial muscle spasms.
with sodium excess or deficit.
d. generalized weakness.
Spironolactone (Aldactone), an aldosterone antagonist, is pre-
scribed for a patient as a diuretic. Which statement by the patient d. I will drink apple juice instead of orange juice for breakfast.
indicates that the teaching about this medication has been effec-
tive? Since spironolactone is a potassium-sparing diuretic, patients
should be taught to choose low potassium foods such as apple
a. I will try to drink at least 8 glasses of water every day. juice rather than foods that have higher levels of potassium, such
as citrus fruits. Because the patient is using spironolactone as a
b. I will use a salt substitute to decrease my sodium intake. diuretic, the nurse would not encourage the patient to increase

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c. I will increase my intake of potassium-containing foods.
fluid intake. Teach patients to avoid salt substitutes, which are high
in potassium.
d. I will drink apple juice instead of orange juice for breakfast.
When caring for a patient admitted with hyponatremia, which
actions will the nurse anticipate taking?
a. Restrict patients oral free water intake.
a. Restrict patients oral free water intake.
To help improve serum sodium levels, water intake is restricted.
b. Avoid use of electrolyte-containing drinks. Electrolyte-containing beverages will improve the patients sodium
level. Administration of vasopressin or hypotonic IV solutions will
c. Infuse a solution of 5% dextrose in 0.45% saline. decrease the serum sodium level further.

d. Administer vasopressin (antidiuretic hormone, [ADH]

Intravenous potassium chloride (KCl) 60 mEq is prescribed for
treatment of a patient with severe hypokalemia. Which action b. Infuse the KCl at a rate of 20 mEq/hour.
should the nurse take?

a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a liter of IV fluid.
A postoperative patient who has been receiving nasogastric suc-
tion for 3 days has a serum sodium level of 125 mEq/L (125
mmol/L). Which of these prescribed therapies that the patient has
been receiving should the nurse question?
Intravenous KCl is administered at a maximal rate of 20 mEq/hr.
Rapid IV infusion of KCl can cause cardiac arrest. Although
the preferred concentration for KCl is no more than 40 mEq/L,
concentrations up to 80 mEq/L may be used for some patients.
KCl can cause inflammation of peripheral veins, but it can be
administered by this route.
a. Infuse 5% dextrose in water at 125 ml/hr.

a. Infuse 5% dextrose in water at 125 ml/hr.

Because the patients gastric suction has been depleting elec-
b. Administer IV morphine sulfate 4 mg every 2 hours PRN. trolytes, the IV solution should include electrolyte replacement.
Solutions such as lactated Ringers solution would usually be
c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for ordered for this patient. The other orders are appropriate for a
nausea. postoperative patient with gastric suction.

d. Administer 3% saline if serum sodium drops to less than 128

mEq/L.
A patient who has required prolonged mechanical ventilation has
the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg,
PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets
these results as
d. respiratory alkalosis
a. metabolic acidosis.
The pH indicates that the patient has alkalosis and the low PaCO2
indicates a respiratory cause. The other responses are incorrect
b. metabolic alkalosis.
based on the pH and the normal HCO3.
c. respiratory acidosis.

d. respiratory alkalosis
The nurse notes that a patient who was admitted with diabetic
ketoacidosis has rapid, deep respirations. Which action should the
nurse take?
a. Notify the patients health care provider.
b. Give the prescribed PRN lorazepam (Ativan).
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Encourage the patient to take deep, slow breaths.
a. Notify the patients health care provider.
The rapid, deep (Kussmaul) respirations indicate a metabolic aci-
dosis and the need for actions such as administration of sodium
bicarbonate, which will require a prescription by the health care
provider. Oxygen therapy is not indicated because there is no in-
dication that the increased respiratory rate is related to hypoxemia.
The respiratory pattern is compensatory, and the patient will not
be able to slow the respiratory rate. Ativan administration will slow
the respiratory rate and increase the level of acidosis.
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The home health nurse notes that an elderly patient has a low
serum protein level. The nurse will plan to assess for
b. edema.
a. pallor.
Low serum protein levels cause a decrease in plasma oncotic
b. edema.
pressure and allow fluid to remain in interstitial tissues, causing
edema. Confusion, restlessness, and pallor are not associated
c. confusion.
with low serum protein levels.
d. restlessness.
A patient is receiving 3% NaCl solution for correction of hypona-
tremia. During administration of the solution, the most important a. lung sounds.
assessment for the nurse to monitor is
Hypertonic solutions cause water retention, so the patient should
a. lung sounds. be monitored for symptoms of fluid excess. Crackles in the lungs
may indicate the onset of pulmonary edema and are the most
b. urinary output. serious of the symptoms of fluid excess listed. Bounding periph-
eral pulses, peripheral edema, or changes in urine output also are
c. peripheral pulses. important to monitor when administering hypertonic solutions, but
they do not indicate acute respiratory or cardiac decompensation.
d. peripheral edema.
The long-term care nurse is evaluating the effectiveness of protein
supplements on a patient who has low serum total protein level.
Which of these data indicate that the patients condition has im- c. Absence of peripheral edema
proved?
Edema is caused by low oncotic pressure in individuals with low
a. Hematocrit 28% serum protein levels; the absence of edema indicates an improve-
ment in the patients protein status. Good skin turgor is an indicator
b. Good skin turgor of fluid balance, not protein status. A low hematocrit could be
caused by poor protein intake. Blood pressure does not provide
c. Absence of peripheral edema a useful clinical tool for monitoring protein status.

d. Blood pressure 110/72 mm Hg

A patient has the following arterial blood gas (ABG) results: pH
7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L.
The nurse interprets these results as
a. metabolic acidosis.
a. metabolic acidosis.

b. metabolic alkalosis. The pH and HCO3 indicate that the patient has a metabolic
acidosis. The ABGs are inconsistent with the other responses.
c. respiratory acidosis.

d. respiratory alkalosis
A patient who has been receiving diuretic therapy is admitted to
the emergency department with a serum potassium level of 3.1
mEq/L. Of the following medications that the patient has been
taking at home, the nurse will be most concerned about a. oral digoxin (Lanoxin) 0.25 mg daily.

a. oral digoxin (Lanoxin) 0.25 mg daily.
b. ibuprofen (Motrin) 400 mg every 6 hours.
c. metoprolol (Lopressor) 12.5 mg orally daily.
Hypokalemia increases the risk for digoxin toxicity, which can
cause serious dysrhythmias. The nurse also will need to do more
assessment regarding the other medications, but there is not as
much concern with the potassium level.

d. lantus insulin 24 U subcutaneously every evening.

A patient with hypercalcemia is being cared for on the medical
d. encouraging fluid intake up to 4000 ml every day.
unit. Nursing actions included on the care plan will include
To decrease the risk for renal calculi, the patient should have
a. maintaining the patient on bed rest.
an intake of 3000 to 4000 ml daily. Ambulation helps decrease
the loss of calcium from bone and is encouraged in patients with
b. auscultating lung sounds every 4 hours.
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c. monitoring for Trousseaus and Chvosteks signs.
d. encouraging fluid intake up to 4000 ml every day.
When teaching a patient with renal failure about a low phosphate
diet, the nurse will include information to restrict
a. ingestion of dairy products.
b. the amount of high-fat foods.
c. the quantity of fruits and juices.
hypercalcemia. Trousseaus and Chvosteks signs are monitored
when there is a possibility of hypocalcemia. There is no indication
that the patient needs frequent assessment of lung sounds, al-
though these would be assessed every shift.
a. ingestion of dairy products.
Foods high in phosphate include milk and other dairy products, so
these are restricted on low-phosphate diets. Green, leafy vegeta-
bles; high-fat foods; and fruits/juices are not high in phosphate and
are not restricted.

d. intake of green, leafy vegetables.

The nurse in the outpatient clinic who notes that a patient has a
decreased magnesium level should ask the patient about
a. daily alcohol intake.
a. daily alcohol intake.
Hypomagnesemia is associated with alcoholism. Protein intake
b. intake of dietary protein. would not have a significant effect on magnesium level. OTC lax-
atives (such as milk of magnesia) and use of multivitamin/mineral
c. multivitamin/mineral use. supplements would tend to increase magnesium level.

d. use of over-the-counter (OTC) laxatives

A patient who has an infusion of 50% dextrose prescribed asks
the nurse why a peripherally inserted central catheter must be
inserted. Which explanation by the nurse is correct?
c. The 50% dextrose is hypertonic and will be more rapidly diluted
a. The prescribed infusion can be given much more rapidly when when given through a central line.
the patient has a central line.
Shrinkage of red blood cells can occur when solutions with dex-
b. There is a decreased risk for infection when 50% dextrose is trose concentrations greater than 10% are administered intra-
infused through a central line. venously. Blood glucose testing is not more accurate when sam-
ples are obtained from a central line. The infection risk is higher
c. The 50% dextrose is hypertonic and will be more rapidly diluted with a central catheter than with peripheral IV lines. Hypertonic or
when given through a central line. concentrated IV solutions are not given rapidly.

d. The required blood glucose monitoring is more accurate when

samples are obtained from a central line.
Which action will the nurse include in the plan of care for a patient
who has a central venous access device (CVAD)?
b. Use the push-pause method to flush the CVAD after giving
a. Avoid using friction when cleaning around the CVAD insertion
medications.
site.
The push-pause enhances the removal of debris from the CVAD
b. Use the push-pause method to flush the CVAD after giving
lumen and decreases the risk for clotting. To decrease infection
medications.
risk, friction should be used when cleaning the CVAD insertion
site. The dressing should be changed whenever it becomes damp,
c. Obtain an order from the health care provider to change CVAD
loose, or visibly soiled and the patient should turn away from the
dressing.
CVAD during cap changes.
d. Have the patient turn the head toward the CAVD during injection
cap changes.
A patient receiving isoosmolar continuous tube feedings develops
restlessness, agitation, and weakness. Which laboratory result is c. Na+ 154 mEq/L (154 mmol/L)
most important to report to the health care provider?
The elevated serum sodium level is consistent with the patients
a. K+ 3.4 mEq/L (3.4 mmol/L) neurologic symptoms and indicates a need for immediate action
to prevent further serious complications such as seizures. The
b. Ca+2 7.8 mg/dl (1.95 mmol/L) potassium and calcium levels vary slightly from the normal but

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c. Na+ 154 mEq/L (154 mmol/L)
do not require any immediate action by the nurse. The phosphate
level is within the normal parameters.
d. PO4-3 4.8 mg/dl (1.55 mmol/L)
A patient who has been hospitalized for 2 days has been receiving
b. Gradually decreasing level of consciousness (LOC)
normal saline IV at 100 ml/hr, has a nasogastric tube to low
suction, and is NPO. Which assessment finding by the nurse is
The patients history and change in LOC could be indicative of
the priority to report to the health care provider?
several fluid and electrolyte disturbances: extracellular fluid (ECF)
excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia,
a. Serum sodium level of 138 mEq/L (138 mmol/L)
or metabolic alkalosis. Further diagnostic information will be or-
dered by the health care provider to determine the cause of the
b. Gradually decreasing level of consciousness (LOC)
change in LOC and the appropriate interventions. The weight gain,
elevated temperature, crackles, and serum sodium level also will
c. Oral temperature of 100.1 F with bibasilar lung crackles
be reported, but do not indicate a need for rapid action to avoid
complications.
d. Weight gain of 2 pounds (1 kg) above the admission weight
hen assessing a patient with increased extracellular fluid (ECF)
c. mental status.
osmolality, the priority assessment for the nurse to obtain is

a. skin turgor.
Changes in ECF osmolality lead to swelling or shrinking of cells
in the central nervous system, initially causing confusion, which
b. heart sounds.
may progress to coma or seizures. Although skin turgor, capillary
refill, and heart sounds also may be affected by ECF osmolality
c. mental status.
changes and resultant fluid shifts, these are signs that occur later
and do not have as immediate an impact on patient outcomes.
d. capillary refill.
A patient with renal failure who has been taking aluminum hy-
c. Review the magnesium level on the patients chart.
droxide/magnesium hydroxide suspension (Maalox) at home for
indigestion is somnolent and has decreased deep tendon reflexes.
The patient has a history and symptoms consistent with hy-
Which action should the nurse take first?
permagnesemia; the nurse should check the chart for a recent
serum magnesium level. Notification of the health care provider
a. Notify the patients health care provider.
will be done after the nurse knows the magnesium level. The
Maalox should be held, but more immediate action is needed to
b. Withhold the next scheduled dose of Maalox.
correct the patients decreased deep tendon reflexes (DTRs) and
somnolence. Monitoring of potassium levels also is important for
c. Review the magnesium level on the patients chart.
patients with renal failure, but the patients current symptoms are
not consistent with hyperkalemia.
d. Check the chart for the most recent potassium level
postoperative patient who is receiving nasogastric suction is com-
plaining of anxiety and incisional pain. The patients respiratory
d. Give the patient the PRN morphine sulfate 4 mg intravenously.
rate is 32 breaths/minute and the arterial blood gases (ABGs)
indicate respiratory alkalosis. Which action should the nurse take
The patients respiratory alkalosis is caused by the increased
first?
respiratory rate associated with pain and anxiety. The nurses
first action should be to medicate the patient for pain. Although
a. Discontinue the nasogastric suctions for a few hours.
the nasogastric suction may contribute to the alkalosis, it is not
appropriate to discontinue the tube when the patient needs gastric
b. Notify the health care provider about the ABG results.
suction. The health care provider may be notified about the ABGs
but is likely to instruct the nurse to medicate for pain. The patient
c. Teach the patient about the need to take slow, deep breaths.
will not be able to take slow, deep breaths when experiencing pain.
d. Give the patient the PRN morphine sulfate 4 mg intravenously.
Which of these actions can the nurse who is caring for a critically
ill patient with multiple intravenous (IV) lines delegate to an expe-
rienced LPN? b. Monitor the IV sites for redness, swelling, or tenderness.

a. Administer IV antibiotics through the implantable port.
b. Monitor the IV sites for redness, swelling, or tenderness.
c. Remove the patients nontunneled subclavian central venous
catheter.
An experienced LPN has the education, experience, and scope of
practice to monitor IV sites for signs of infection. Administration of
medications, adjustment of infusion rates, and removal of central
catheters in critically ill patients require RN level education and
scope of practice.

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d. Adjust the flow rate of the 0.9% normal saline in the peripheral
IV line.
Which assessment finding about a patient who has a serum
calcium level of 7.0 mEq/L is most important for the nurse to report
to the health care provider?
a. The patient is experiencing laryngeal stridor.
a. The patient is experiencing laryngeal stridor.
Laryngeal stridor may lead to respiratory arrest and requires rapid
action to correct the patients calcium level. The other data also
b. The patient complains of generalized fatigue.
are consistent with hypocalcemia, but do not indicate a need for
immediate action.
c. The patients bowels have not moved for 4 days.

d. The patient has numbness and tingling of the lips.

Following a thyroidectomy, a patient complains of a tingling feeling
around my mouth. The nurse will immediately check for
b. the presence of Chvosteks sign.
a. an elevated serum potassium level.
The patients symptoms indicate possible hypocalcemia, which
b. the presence of Chvosteks sign.
can occur secondary to parathyroid injury/removal during thy-
roidectomy. There is no indication of a need to check the potassi-
c. a decreased thyroid hormone level.
um level, the thyroid hormone level, or for bleeding.
d. bleeding on the patients dressing.
A patient with advanced lung cancer is admitted to the emergency
department with urinary retention caused by renal calculi. Which
of these laboratory values will require the most immediate action b. Serum calcium is 18 mEq/L.
by the nurse?
The serum calcium is well above the normal level and puts the
a. Arterial blood pH is 7.32. patient at risk for cardiac dysrhythmias. The nurse should initiate
cardiac monitoring and notify the health care provider. The potas-
b. Serum calcium is 18 mEq/L. sium, oxygen saturation, and pH also are abnormal, and the nurse
should notify the health care provider about these values as well,
c. Serum potassium is 5.1 mEq/L. but they are not immediately life-threatening.

d. Arterial oxygen saturation is 91%.

The following data are obtained by the nurse when assessing a
pregnant patient with eclampsia who is receiving IV magnesium b. The patellar and triceps reflexes are absent.
sulfate. Which finding is most important to report to the health care
provider immediately?
The loss of the deep tendon reflexes indicates that the patients
a. The bibasilar breath sounds are decreased. magnesium level may be reaching toxic levels. Nausea and lethar-
gy also are side effects associated with magnesium elevation and
b. The patellar and triceps reflexes are absent. should be reported, but they are not as significant as the loss
of deep tendon reflexes. The decreased breath sounds suggest
c. The patient has been sleeping most of the day. that the patient needs to cough and deep breathe to prevent
atelectasis.
d. The patient reports feeling sick to my stomach.
The nurse has administered 3% saline to a patient with hypona-
tremia. Which one of these assessment data will require the most
rapid response by the nurse? d. There are crackles audible throughout both lung fields.

a. The patients radial pulse is 105 beats/minute.
b. There is sediment and blood in the patients urine.
c. The blood pressure increases from 120/80 to 142/94.
Crackles throughout both lungs suggest that the patient may be
experiencing pulmonary edema, a life-threatening adverse effect
of hypertonic solutions. The increased pulse rate and blood pres-
sure and the appearance of the urine also should be reported, but
they are not as dangerous as the presence of fluid in the alveoli

d. There are crackles audible throughout both lung fields.

The patient taking furosemide (Lasix) to correct excess edema

shows a weight loss of 5.5 pounds in 24 hours. The nurse calcu-
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lates this weight loss to be the excretion of approximately _____
liters of fluid.

a. 1.0 d. 2.5

b. 1.5 Each kilogram (2.2 pounds) of weight loss is equivalent to 1 liter

of fluid. Therefore, 5.5 pounds 2.2 pounds = 2.5 liters.
c. 2.0

d. 2.5
While the nurse is washing the face of a patient in renal failure,
the patient demonstrates a spasm of the lips and face. The nurse
examines the recent electrolyte levels to assess the level of:
b. calcium.
a. potassium.
Chvosteks sign is a signal of hypocalcemia. It occurs when the
b. calcium. facial nerve is tapped or stroked about an inch in front of the
earlobe and results in unilateral twitching of the face.
c. sodium.

d. magnesium.
Prior to hanging an IV containing potassium, the nurse will confirm
that there is a:
b. urine output of at least 30 mL/hr.
a. blood pressure of at least 60 mm Hg diastolic.
An adequate urine output must be present prior to the adminis-
b. urine output of at least 30 mL/hr.
tration of potassium to ensure adequate excretion of potassium,
preventing hyperkalemia.
c. filter on the IV line.

d. pulse of at least 50 beats/min.

A client has a serum sodium level of 129 mEq/L. The nurse
should prepare to administer which of the following intravenous
solutions? c. 0.9% Normal Saline

a. Dextrose 5% and Lactated Ringer Normal saline (0.9%) is commonly provided to restore extracel-
lular fluid volume and increase sodium levels. Dextrose 5% and
b. Dextrose 5% and 0.45% Normal Saline Lactated Ringers, Dextrose 5% and 0.45% Normal Saline, and
Dextrose 5% and 0.9% Normal Saline are hypertonic solutions,
c. 0.9% Normal Saline and they will move water from the cells into the bloodstream.

d. Dextrose 5% and 0.9% Normal Saline

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