Saunders NCLEX~Fluids and electrolytes

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1. A client is at risk for developing hypocalcemia. Positive Trousseau's sign,

The nurse determines which signs are associ- Fine tremors noted in
ated with this electrolyte disturbance? Select hands
all that apply.

2. The nurse is caring for a client with a nasogas- Utilize 30 mL of 0.9% nor-
tric tube in place for gastric decompression. mal saline for the irrigat-
The primary health care provider (PHCP) pre- ing solution, After injecting
scribes to have the tube irrigated once every the irrigating solution, pull
8 hours. Select the correct interventions the back on the irrigation sy-
nurse should utilize in performing this proce- ringe.
dure. Select all that apply.

3. The nurse is caring for a client who has been Increased specific gravity
taking diuretics on a long-term basis. Which of the urine
finding should the nurse expect to note as a
result of this long-term use?

4. The nurse is caring for a group of clients on a The client with renal fail-
clinical nursing unit. The nurse interprets that ure, The client with chronic
which assigned clients are at risk for excess cirrhosis
fluid volume? Select all that apply.

5. The nurse is instructing a client on how to Butter

decrease the intake of calcium in the diet. The
nurse should tell the client that which food
item is least likely to contain calcium?

6. Which of these clients are most likely to devel- A premature infant, A

op fluid (circulatory) overload? Select all that 101-year-old man, A client
apply. with heart failure, A client
receiving renal dialysis

7. The nurse is caring for a client with kidney fail- Loss of deep tendon re-
ure. The laboratory results reveal a magnesium flexes
level of 3.6 mEq/L (1.8 mmol/L). Which sign
should the nurse expect to note in the client,
based on this magnesium level?

8. Calcitonin
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The nurse is caring for a client with hyper-
parathyroidism and notes that the client's
serum calcium level is 13 mg/dL (3.25 mmol/L).
Which prescribed medication should the nurse
plan to assist in administering to the client?

9. The nurse is caring for a group of clients on A client with pneumonia, A

a clinical nursing unit. The nurse checks for client with an ileostomy, A
signs of deficient fluid volume. Which clients client with a temperature
are at risk for this fluid imbalance? Select all of 102.5° F (39.2° C)
that apply.

10. The metabolic panel of a client reveals a calci- Presence of Chvostek's

um level of 6.5 mg/dL (1.6 mmol/L). Based on sign, Presence of electro-
this laboratory finding, which additional data cardiogram abnormalities,
specific to this calcium level should the nurse Presence of tingling in the
collect? Select all that apply. fingertips and around the
mouth, Presence of carpal
spasm when blood pres-
sure cuff is inflated above
systolic blood pressure for
a few minutes

11. A 0.9% intravenous (IV) solution is prescribed Is the same solution as

for a client. The IV is to run at 100 mL/hr. The sodium chloride 0.9%, Is
nurse prepares the solution, understanding used to administer red
that which are characteristics of this type of blood cell transfusion, Is
solution? Select all that apply. used to treat hypotension
due to fluid volume deficit

12. A client enters the emergency department con- Monitor vital signs. Moni-
fused, twitching, and having seizures. Upon tor intake and output. In-
assessment, flushed skin, dry mucous mem- crease water intake orally.
branes, an elevated temperature, and poor Monitor electrolyte levels.
skin turgor is noted. The serum sodium level Provide a sodium-reduced
is 172 mEq/L (172 mmol/L). Which interven- diet.
tions should the primary health care provider
(PHCP) likely prescribe? Select all that apply.

13. Vitamin D
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 Saunders NCLEX~Fluids and electrolytes
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A client undergoing renal dialysis is pre-
scribed calcitriol to treat hypocalcemia. The
nurse reinforces instructions and informs the
client that this medication is also known as
which nutrient?

14. Etidronate, an antihypercalcemic medication, Take 2 hours before

is prescribed for a client. Which information meals.
should the nurse reinforce when instructing
the client about taking this medication?

15. The nurse is caring for a client with a sus- Generalized muscle weak-
pected diagnosis of hypercalcemia. Which ness
sign/symptom would be an indication of this
electrolyte imbalance?

16. The nurse is reviewing the health care records The client with renal fail-
of assigned clients. Which clients are at high- ure, The client with chron-
est risk for excess fluid volume? Select all that ic congestive heart failure
apply. (CHF)

17. The nurse reviews a client's electrolyte results Cushing's syndrome

and notes a potassium level of 5.5 mEq/L (5.5
mmol/L). The nurse understands that a potas-
sium value at this level would be noted with
which condition?

18. The nurse is reviewing the health records of The client with a ileostomy
assigned clients. The nurse should plan care
knowing that which client is at risk for fluid
volume deficit?

19. A client is admitted with a diagnosis of pneu- Flat neck veins, Weakly
monia and dehydration. The nurse monitors palpable peripheral puls-
the client and determines which symptoms es, Heart rate of 104 beats
correlate with this client's fluid imbalance? Se- per minute
lect all that apply.

20. A client with a history of

alcoholism
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The nurse is caring for a group of clients.
Which client is most likely to have a serum
phosphorus level of 2.0 mg/dL (0.64 mmol/L)?

21. The nurse is caring for a client with leukemia Postural blood pressure
and notes that the client has poor skin changes
turgor and flat neck and hand veins. The
nurse suspects hyponatremia. Which addition-
al sign/symptom should the nurse expect to
note in this client if hyponatremia is present?

22. The nurse is reviewing the health records of The client with diabetes
assigned clients. The nurse should plan care mellitus
knowing that which client is at the least likely
risk for the development of third-spacing?

23. The nurse is caring for a client whose mag- Hypotension, Loss of deep
nesium level is 3 mEq/L (1.5 mmol/L) and the tendon reflexes
client is being treated for the magnesium im-
balance. The nurse interprets that the elec-
trolyte imbalance is resolving if which signs
or symptoms are no longer present? Select all
that apply.

24. The nurse is reviewing the laboratory results Monitor the client for dys-
of a client hospitalized with a diagnosis of rhythmias, Notify the pri-
Crohn's disease. The client has a magnesium mary health care provider
level of 1.0 mEq/L (0.5 mmol/L). Which nursing (PHCP) of the laboratory
interventions should the nurse initiate? Select results.
all that apply.

25. The nurse is assisting in the care of a client Ileostomy output of 650
with a new ileostomy on the clinical nursing mL in 4 hours, Blood pres-
unit. Which observations indicate to the nurse sure (BP) 104/66 mmHg,
that the client is at risk for fluid volume deficit? temperature 98.4° F, pulse
Select all that apply. 106 beats per minute, res-
pirations 20 breaths per
minute

26.
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 Saunders NCLEX~Fluids and electrolytes
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The nurse reviews an assigned client's labora- Severe burn injury, Un-
tory report and notes a serum potassium level treated ketoacidosis
of 5.5 mEq/L (5.5 mmol/L). The nurse should
determine that this is an expected finding if the
client had which health problems? Select all
that apply.

27. A client has a nasogastric tube in place that Hypokalemia, Hypona-

is attached to suction. The client is at risk for tremia, Hypomagnesemia
developing which electrolyte imbalances with
prolonged suction? Select all that apply.

28. The nurse is caring for a client with a diagno- Inform the registered
sis of hyperparathyroidism. Laboratory stud- nurse of the laboratory val-
ies are performed and the serum calcium lev- ue.
el is 12.0 mg/dL (3.0 mmol/L). Based on this
laboratory value, the nurse should take which
action?

29. A client needs to be placed on strict intake Pulling up and releasing

and output (I&O) measurement. The nurse col- the skin on the sternal
lects the data as a baseline and then checks area
the client's skin turgor by doing which action?
Refer to video. Click on the Question Video
button to view a video showing preparation
procedures.

30. The nurse reviews electrolyte values and notes The client with the syn-
a sodium level of 130 mEq/L (130 mmol/L). The drome of inappropriate se-
nurse expects that this sodium level would be cretion of antidiuretic hor-
noted in a client with which condition? mone

31. A client enters the emergency department con- Monitor vital signs. Moni-
fused, twitching, and having seizures. His fam- tor electrolyte levels. Mon-
ily states he recently was placed on corticos- itor intake and output. In-
teroids for arthritis and was feeling better and crease water intake orally.
exercising daily. On data collection, he has Maintain sodium-reduced
flushed skin, dry mucous membranes, an el- diet.
evated temperature, and poor skin turgor. His
serum sodium level is 150 mEq/L (150 mmol/L).
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Which interventions would the primary health
care provider likely prescribe? Select all that
apply.

32. The nurse who is caring for a client with kid- An increase in blood pres-
ney failure notes that the client is dyspne- sure
ic and crackles are heard when listening to
breath sounds in the lungs. Which additional
sign/symptom should the nurse expect to note
in this client?

33. The nurse is reviewing the health records of The client receiving naso-
assigned clients. The nurse should plan care gastric suction
knowing that which client is at risk for a potas-
sium deficit?

34. The nurse is told in a report that the client has Tetany, A positive
hypocalcemia. Which signs should the nurse Chvostek's sign, A positive
expect to note during the data collection? Se- Trousseau's sign
lect all that apply.

35. The nurse checks a client's skin turgor and The skin when pinched im-
documents that the client exhibits normal fluid mediately fell back to nor-
balance. Which statement correctly describes mal when released.
what the nurse has documented?

36. The nurse is assisting in the care of a client Left foot has 4+ pitting
with a left foot that sustained a crush injury. edema.
The nurse determines that the client developed
third spacing of body fluid based on which
observation?

37. The nurse is monitoring the fluid balance of a Monitoring for decreased
client with advanced human immunodeficien- urine output and hypoten-
cy virus (HIV) infection. Because the client has sion
lost a great deal of weight and muscle mass,
the nurse understands that which action will
provide a reliable indicator of fluid balance?

38. 2520
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 Saunders NCLEX~Fluids and electrolytes
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The nurse is calculating a client's 24-hour fluid
intake. The client consumed coffee (8 oz), wa-
ter (8 oz), and orange juice (6 oz) for breakfast;
soup (4 oz) and iced tea (8 oz) for lunch; and
milk (10 oz), tea (8 oz), and water (8 oz) for
dinner. The client also consumed 24 oz of water
during the day. How many milliliters of fluid did
the client consume in the 24-hour period? Fill
in the blank.

39. Which electrocardiogram changes would the U waves

nurse note on the cardiac monitor with a client
whose potassium (K+) level is 2.7 mEq/L (2.7
mmol/L)?

40. The nurse is assisting in the care of a client Weakness in all extremi-
who has a serum sodium level of 128 mEq/L ties, Confusion with gar-
(128 mmol/L). The nurse relates which of the bled speech, Diarrhea with
client's signs and symptoms to this electrolyte abdominal cramping
imbalance? Select all that apply.

41. Which fluids are identified as insensible fluid Sputum, sweat

losses? Select all that apply.

42. The nursing instructor asks the student to de- "Water and electrolytes
scribe isotonic dehydration. The student cor- are lost in approximate-
rectly responds by stating which pathophys- ly the same proportion as
iological processes are occurring? Select all they exist in the body."
that apply.

43. The nurse is reading the primary health care The client with a fast respi-
provider's (PHCP's) progress notes in the ratory rate
client's record and sees that the PHCP has
documented "insensible fluid loss of approxi-
mately 800 mL daily." Which client is at risk for
this loss?

44. The nurse is assisting in caring for a client who Muscle weakness
is receiving an intravenous infusion of 1000
mL of normal saline with 40 mEq of potassium
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 Saunders NCLEX~Fluids and electrolytes
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chloride. The nurse is monitoring the client for
signs of hyperkalemia. Which sign/symptom
should be noted in the client if hyperkalemia
is present?

45. The nurse is assigned to care for a group of Hypertension

clients on the clinical nursing unit. Which client
is least likely to develop third spacing of flu-
ids?

46. The nurse is assisting in caring for a client with Administer hypertonic nor-
severe hyponatremia resulting from hyperv- mal saline solution intra-
olemia. The nurse anticipates which treatment venously.
would be prescribed by the primary health care
provider?

47. A client has a serum sodium level of 129 Restrict fluid intake. Mon-
mEq/L (129 mmol/L) because of hypervolemia. itor electrolytes every 24
The nurse anticipates the primary health care hours.
provider to prescribe which measures? Select
all that apply.

48. The nurse reviews the client's serum calcium Prolonged bed rest
level and notes that the level is 8.0 mg/dL (2.0
mmol/L). The nurse understands that which
condition would cause this serum calcium lev-
el?

49. The nurse reviews a client's electrolyte results Narrow, peaked T waves
and notes that the potassium level is 5.4 mEq/L
(5.4 mmol/L). What should the nurse look for
on the cardiac monitor as a result of this labo-
ratory value?

50. The nurse is planning to reinforce dietary Eat salads with cab-
teaching about following a diet that is low in bage and lettuce and
potassium to a client receiving a potassium-re- avoid spinach. Avoid eat-
taining (sparing) diuretic. The nurse should be ing lunch meats and
sure to include which strategies to avoid foods bolognas. Use eggs as a
source for protein.
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high in potassium in the diet? Select all that
apply.

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