Fluid and Electrolyte NCLEX Questions

Fluid and Electrolyte NCLEX Questions ScienceMedicineNursing jgeorge28 Save Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Fluid and Electrolytes NCLEX Quest...96 terms daniela_alldredge Preview Fluids and Electrolytes NCLEX 53 terms SetfiretoitPreview Med Su 86 terms Jas The nurse is caring for a client with heart failure. On Assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

• - weight loss
• - Flat neck and head veins
• - An increase in BP
• - Decreased central venous pressure
• - Increase in BP

Reason:

-Dyspneic - difficulty breathing and crackles are findings of fluid volume excess (overhydration) -The other symptoms would not match because they should be the opposite (weight gain, distended veins, elevated CVP) The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client record and determines that the client was at risk for developing the potassium deficit because of which situation?

• - Sustained tissue damage
• - Requires nasogastric suction
• - Has a history of Addison's disease
• - Is taking potassium-retaining diuretics
• - Required nasogastric suction

Reason:

• Hyopkalemia - potassium deficit (normal levels 3.5 mEq/L - 5.0 mEq/L)
• The other points are risks for HYPERkalemia

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrolyte cardiogram as a result of the lab value?

• - U waves
• - Absent P waves
• - Elevated T waves
• - Elevated ST segment
• - U waves

Reason:

• Level is below normal limit (HYPO)
• This results in the following ECG results: ST depression, shallow/flat/inverted T wave, prominent U wave

The nursing student needs to administer potassium chloride IV as prescribed to client with hypokalemia. The instructor determines that the student is unprepared if the student states that which action is part of the plan for preparation and administration of the potassium?

• - obtaining IV infusion pump
• - Monitoring urine output during administration
• - Preparing the medication for bolus administration
• - Ensuring the med is diluted in the appropriate amount of normal saline
• - Preparing for bolus administration

Reason:

• Bolus = IV push
• Potassium is NEVER given by IV push (AKA bolus)

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells them to consume which of the following (select all that apply)?

• - Peas
• - Raisins
• - Potatoes
• - Cantaloupe
• - Cauliflower
• - Strawberries

Raisins, Potatoes, cantaloupe, strawberries

The nurse is reviewing lab results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the level to the health care provider and they prescribe dietary instructions based on the sodium level. Which food does the client need to avoid?

• - Peas
• - Nuts
• - Cauliflower
• - Processed oat cereals
• - Processed oat cereal

Reason:

- Normal levels: 135 - 145 mEq/L

• The patient has an elevated level meaning they should not consume sodium rich foods, and processed foods have elevated amounts of

sodium The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note?

• - twitching
• - Hypoactive bowel sounds
• - Negative Trousseau's sign
• - Hypoactive deep tendon reflexes
• - Twitching

Reason:

• This is a common finding in hypocalcemia
• The rest of the symptoms are associated with HYPERcalcemia

The nurse is caring for a client with hypocalcemia would expect to note which change to the ECG?

• - Widened T wave
• - Prominent U wave
• - Prolonged QT interval
• - Shortened ST segment
• - Prolonged QT interval

reason:

• ECG findings in hypocalcemia include: prolonged QT interval and prolonged ST segment

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the ECG as a result?

• - ST depression
• - Inverted T wave
• - Prominent U wave
• - Tall peaked T wave
• - Tall peaked T wave

Reason:

- Normal potassium levels: 3.5 - 5.0 mEq/L

• This patient is HYPERkalemic meaning the ECG results would be: tall peaked T waves, flat P waves, widened QRS complex, prolonged PR

interval The nurse caring for a group of clients reviews the electrolyte lab results and notes a sodium level of 130 mEq/L on one lab report. The nurse understands that which client is at the highest risk for development of this sodium level value?

• - the client taking diuretics
• - the client with hyperaldosteronism
• - the client with Cushing's Syndrome
• - the client taking corticosteroids
• - the client taking diuretics

Reason:

- Normal sodium levels: 135 - 145 mEq/L

• This patient is HYPOnatremic
• Most times salt follows water, so diuretics cause loss of Na as well

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect in hyponatremia?

• - Muscle twitches
• - Dec urinary output
• - Hyperactive bowel sounds
• - Increased specific gravity of urine
• - Hyperactive bowel sounds

Reason:

(from all nurses) fluid moves from a lower concentration to a higher concentration. Since there is hyponatremia (low concentration of sodium in the blood), the body will try to even up the ratio, so the fluid might move into the digestive tract. this movement may cause increased peristalsis (for excretion).