Fluid and Electrolyte NCLEX Questions with Explanations

Fluid and Electrolyte NCLEX Questions with Explanations Mfb325811 Save Chapter 6 10 terms Maggie_Kutner Preview Chest Tube NCLEX questions

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abcdefghijkay Preview Ch.5 - C 10 terms Tre The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic (labored breathing), and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

• Weight loss and dry skin
• Flat neck and hand veins and decreased urinary output
• An increase in blood pressure and increased respirations
• Weakness and decreased central venous pressure (CVP)
• An increase in blood pressure and increased respirations

Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit.Weakness can be present in either fluid volume excess or deficit.The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?

• Sustained tissue damage
• Requires nasogastric suction
• Has a history of Addison's disease
• Uric acid level of 9.4 mg/dL (559 μmol/L)
• 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 (0.16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL(0.24 to 0.51 mmol/L). Hyperuricemia is cause of hyperkalemia.

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for the preparation and administration of the potassium? Select all that apply.

• Obtain an intravenous (IV) infusion pump.
• Monitor urine output during administration.
• Prepare the medication for bolus administration.
• Monitor the IV site for signs of infiltration or phlebitis.

E.. Ensure that the medication is diluted in the appropriate volume of fluid.

• Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

A, B, D, E, F

Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely because potassium chloride is irritating to the veins and there is a risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour.The nurse reviews laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume?Select all that apply.

• Peas
• Nuts
• Cheese
• Cauliflower
• Processed oat cereals

A, B, D

Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium.Processed foods such as cheese and processed oat cereals are high in sodium content.The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

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

Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesia followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

Which client is at risk of developing a sodium level at 130 mEq/L (130 mmol/L)?

• The client who is taking diuretics
• The client with hyperaldosteronism
• The client with Cushing's syndrome
• The client who is taking corticosteroids
• The client who is taking diuretics

Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing’s syndrome are at risk for hypernatremia.The nurse is caring for a client with heart failure who receives high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

• Muscle twitches
• Decreased urinary output
• Hyperactive bowel sounds
• Increased specific gravity of the urine
• Hyperactive bowel sounds

Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level?

• Malnutrition
• Renal insufficiency
• Hypoparathyroidism
• Tumor lysis syndrome
• Malnutrition

Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide– based or magnesium based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP 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?

• Urinary output
• Wound drainage
• Integumentary output
• The gastrointestinal tract
• 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 that the person is aware of, such as through urination, wound drainage, and gastrointestinal tract losses.The nurse is assigned to care for a group of clients. On reviewing the clients' medical records, the nurse determines which client is most likely at risk for a fluid volume deficit?

• A client with an ileostomy
• A client with heart failure
• A client on long-term corticosteroid therapy
• A client receiving frequent wound irrigations
• A client with an ileostomy

Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the body’s fluid needs. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit.Which assessment finding would the nurse note in a client with this condition?

• Weight loss and poor skin turgor
• Lung congestion and increased heart rate
• Decreased hematocrit and increased urine output
• Increased respiration and increased blood pressure
• Weight loss and poor skin turgor

Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the body’s fluid needs. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP) (normal CVP is between 4 and 11 cm H2O), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.