NCLEX Review - l OM oAR cP SD | 57 81 9 35 7 N121 GSS Spring 2...

l OM oAR cP SD | 57 81 9 35 7

l OM oAR cP SD | 57 81 9 35 7

N121 GSS Spring 2025: Electrolytes and GI

NCLEX Review 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?

• Sustained tissue damage
• Requires NG suction
• Has a hx of Addison’s disease
• Is taking Spironolactone
• The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/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 taking a potassium-retaining diuretic are at risk for hyperkalemia.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.

• Peas
• Raisins
• Potatoes
• Cantaloupe
• Cauliflower
• Strawberries
• C. D. F. The normal potassium level is 3.5 to 5.0 mEq/L. Common food sources of potassium include avocado,

bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.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
• The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates

hypocalcemia. Signs of hypocalcemia include paresthesias 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.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 corticosteroid
• Hyponatremia is evidenced by a serum sodium level less than 135 mEq/L. 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. 1 / 3

l OM oAR cP SD | 57 81 9 35 7

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 hyponatremi a. 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 urine
• Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/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 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?

• Client with an ileostomy
• Client with heart failure
• Client on long-term corticosteroids
• Client receiving frequent wound irrigations
• A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. 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, are most at risk for fluid volume excess.A client is admitted with hypokalemia and skeletal muscle weakness. Which assessment does the nurse perform first?

• Blood pressure
• Pulse
• Respirations D. Temperature
• Respiratory changes are likely because of weakness of the muscles needed for breathing. Skeletal muscle weakness

results in shallow respirations. Thus, respiratory status should be assessed first in any client who might have hypokalemia. Blood pressure and pulse will be altered in this client, but they are not the priority assessment.Temperature is not a priority assessment for the client with hypokalemia.The nurse is assessing a client with hyponatremia. Which finding requires immediate action?

• Diminished bowel sounds
• Heightened acuity
• Muscular weakness
• Urine output of 35 mL/hr
• Muscle weakness in clients with hyponatremia requires immediate action. If muscle weakness is present,

immediately check respiratory effectiveness because ventilation is dependent on adequate strength of the respiratory muscles. Excessive bowel sounds, not diminished bowel sounds, are expected in the client with hyponatremia, as well as mild confusion, not heightened acuity. A urine output of 35 mL/hr is normal (minimally) and does not require immediate action.The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical?

• Monitoring 24-hour urine output
• Asking the client about feeling depressed
• Hourly deep tendon reflexes (DTRs)
• Monitoring of serum calcium levels
• The client who is receiving IV magnesium sulfate should be assessed for signs of toxicity every hour by assessment

of DTRs. Most clients who have fluid and electrolyte problems will be monitored for intake and output; this will not immediately generate data about problems with magnesium overdose. Low magnesium levels can cause psychological depression, but assessing this parameter as the levels are restored would not be a method by which to safely assess a safe dose or an overdose. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.A client is admitted to the nursing unit with a diagnosis of hypokalemia. Which assessment does the nurse complete first? 2 / 3

l OM oAR cP SD | 57 81 9 35 7

• Auscultating bowel sounds
• Checking deep tendon reflexes (DTRs)
• Determining the level of consciousness (LOC)
• Obtaining a pulse oximetry reading
• Because hypokalemia may cause respiratory insufficiency and respiratory arrest, the client’s respiratory status

should be assessed first. Bowel sounds, DTRs, and LOC may change in a client with hypokalemia, but these changes are not immediately life-threatening.A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure. Her laboratory results include a potassium level of 7.0 mEq/L. What is the primary goal of drug therapy for this client?

• Decreasing cardiac contractility and slowing the heart rate
• Elevating serum potassium levels to a safe range
• Maintaining proper diuresis and urine output
• Restoring fluid balance by controlling the causes of dehydration
• Drug therapy for dehydration is directed at restoring fluid balance and controlling the causes of dehydration.

Hyperkalemia (serum potassium level of 7.0) will slow the cardiac rate and cause decreased contractility of the heart.Serum potassium levels are already critically high, so should not be elevated further. Excessive diuretic use is what has caused this client’s problems. What she needs now is to have electrolyte balance restored; for potassium, that is 3.5 to 5.0 mEq/L Which client is at increased risk for fluid and electrolyte imbalance? (Select all that apply.)

• A 22-year-old pregnant woman in her third trimester
• A 24-year-old male athlete
• A 65-year-old man on diuretics
• A 47-year-old man traveling to South America in summer
• A 76-year-old bedridden woman
• C. E. An athlete is at risk for dehydration. An older man on diuretics is at risk for fluid and electrolyte imbalances

owing to the action(s) of the drugs. Many of the high-ceiling (loop) diuretics cause loss of potassium as they enable the body to rid itself of excess fluids. Older adults have decreased thirst mechanisms and are at risk for dehydration and subsequent fluid and electrolyte problems. A middle-aged man who is traveling to a hot climate and/or high altitude is at risk for insensible water loss as he acclimates to warmer temperatures. A pregnant client in the third trimester does have an increase in total body fluids, but this accumulation occurs gradually throughout the pregnancy.A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). She is receiving lactated Ringer’s solution IV for rehydration. What clinical manifestations does the nurse monitor during rehydration of the client? (Select all that apply.)

• Blood serum glucose
• Blood pressure
• Pulse rate and quality
• Urinary output
• Urine specific gravity levels

B.C.D.E. As fluid within the vascular space increases, the blood pressure should also increase, along with the pulse rate and quality. Urinary output should also increase as the kidneys filter additional blood volume. Urine specific gravity levels should decrease, as a result of more dilute urine from additional fluid.Which newly written prescription does the nurse administer first? A.Intravenous normal saline to a client with a serum sodium of 132 mEq/L

• Oral calcium supplements to a client with severe osteoporosis
• Oral phosphorus supplements to a client with acute hypophosphatemia
• Oral potassium chloride to a client whose serum potassium is 3 mEq/L
• Because minor changes in serum potassium level can cause life-threatening dysrhythmias, the first priority should

be to administer potassium supplements to the client with hypokalemia. The electrolyte disturbances (sodium level of 132 and low phosphorus level) and the need for calcium in the other clients are not immediately life-threatening.

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