NCLEX QUESTIONS
FLUID AND ELECTROLYTES
1.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 hand veins
- An increase in blood pressure
- Decreased central venous pressure (CVP)
- An increase in blood pressure
- Sustained tissue damage
- Requires nasogastric suction
- Has a history of Addison's disease
- Is taking a potassium-retaining diuretic
- Requires nasogastric suction
- U waves
- Absent P waves
- Elevated T waves
- Elevated ST segment
- U waves
- Peas
- Raisins
- Potatoes
- Cantaloupe
- Cauliflower
- Strawberries
2.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 was at risk for developing the potassium deficit because of which situation?
3.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 electrocardiogram as a result of the laboratory value?
4.The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.
o2. Raisins
o3. Potatoes o4. Cantaloupe o6. Strawberries 5.The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/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 food item does the nurse instruct the client to avoid?
- Peas
- Nuts
- Cauliflower
- Processed oat cereals
- Processed oat cereals
- Twitching
- Hypoactive bowel sounds
- Negative Trousseau's sign
- Hypoactive deep tendon reflexes
- Twitching
- Widened T wave
- Prominent U wave
- Prolonged QT interval
- Shortened ST segment
- Prolonged QT interval
- ST depression
- Inverted T wave
- Prominent U wave
- Tall peaked T waves
- Tall peaked T waves
6.The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
7.The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)?
8.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 electrocardiogram as a result of the laboratory value?
9.The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?
- 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
- Muscle twitches
- Decreased urinary output
- Hyperactive bowel sounds
- Increased specific gravity of the urine
- Hyperactive bowel sounds
- Alcoholism
- Renal insufficiency
- Hypoparathyroidism
- Tumor lysis syndrome
- Alcoholism
- The skin
- Urinary output
- Wound drainage
- The gastrointestinal tract
- The skin
10.The nurse is caring for a client with heart failure who is receiving 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?
11.The nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2 mg/dL. Which condition most likely caused this serum phosphorus level?
12.The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route?
13.The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that 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
- Lung congestion
- Decreased hematocrit
- Increased blood pressure
- Decreased central venous pressure (CVP)
- Decreased central venous pressure (CVP)
- The client taking diuretics
- The client with kidney disease
- The client with an ileostomy
- The client who requires gastrointestinal suctioning
- The client with kidney disease
- The client with colitis
- The client with Cushing's syndrome
- The client who has been overusing laxatives
- The client who has sustained a traumatic burn
- The client who has sustained a traumatic burn
- 0.9% normal saline
- 0.45% normal saline
- Lactated Ringer's solution
- 5% dextrose in 0.9% normal saline
- 5% dextrose in 0.9% normal saline
14.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?
15.The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?
16.The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is most at risk for the development of a potassium value at this level?
17.Which intravenous solution would be most appropriate for a client who may be experiencing excess fluid volume secondary to heart failure?