NCLEX-Fluid & Electrolytes

The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which client is at risk for this fluid imbalance?

1. A client with an ileostomy

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

1. A premature infant 2. A 101-year-old man 3. A client on renal dialysis 4. A client with heart failure

Calcitriol (Rocaltrol) is prescribed for the client with hypocalcemia. The nurse instructs the client to avoid excessive amounts of which food item that interfere with calcium absorption?

1. Bran

A client is 3 days postoperative from gastric surgery and still has a nasogastric tube in place. The client is at risk to develop which electrolyte imbalances? Select all that apply.

1. Hypokalemia 3. Hyponatremia 5. Hypomagnesemia

The nurse is assisting in the care of a group of clients on the clinical nursing unit. The nurse monitors the fluid balance of a client who has which diagnosis and is most at risk for fluid volume deficit?

1. Ileostomy

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.3 mg/dL. Which is the most appropriate nursing intervention?

1. Monitor the client for dysrhythmias.

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.

1. Monitor vital signs 2. Monitor intake 3. Increase water intake orally 4. Monitor electrolyte levels 5. Provide a sodium-reduced diet

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.

1. Monitor vital signs. 2. Monitor electrolyte levels. 3. Increase water intake orally. 4. Monitor intake and output. 5. Maintain sodium-reduced diet.

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?

1. Obtain orthostatic vital signs.

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL. Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.

1. Presence of Chevstek's sign 4. Presence of electrocardiogram abnormalities 5. Presence of tingling in the fingertips and around the mouth 6. Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands which condition causes this serum calcium level?

1. Prolonged bed rest

A client has a serum sodium level of 129 mEq/L because of hypervolemia. The nurse consults with the health care provider to determine whether which measure should be instituted?

1. Restricting fluid intake

A registered nurse (RN) is discussing the overall fluid balance of an assigned client. The RN records that the client's insensible fluid loss is approximately 500 mL/day. The licensed practical nurse (LPN) recalls that the RN is referring to fluid losses occurring through which areas?

1. Skin and lungs

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned client is at risk for excess fluid volume?

1. The client with renal failure

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

1. U waves

The nurse is obtaining the intershift report for a group of assigned clients. The nurse plans to monitor which client for signs of hyperkalemia because of the physiology associated with the health problem?

2. A client with a new burn injury

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

2. Butter

The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained by the nurse?

2. Decreasing body weight

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which symptom that correlates with this client's fluid imbalance?

2. Flat neck veins

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. Based on this laboratory value, the nurse should take which action?

2. Inform the registered nurse of the laboratory value.

A normal saline 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which is a characteristic of this type of solution?

2. Is the same solution as sodium chloride 0.9%

The nurse is told in a report that the client has hypocalcemia and a positive Chvostek's sign. Which signs should the nurse expect to note during the data collection? Select all that apply.

2. Tetany 3. Diarrhea 5. A positive Trousseau's sign

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

2. The client with a colostomy

The nurse is reviewing the health care records of assigned clients. Which client is at risk for excess fluid volume?

2. The client with renal failure

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level should be noted with which condition?

2. Traumatic burn

The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (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.

2520 mL

A client has been admitted to the hospital with a diagnosis of severe nausea and vomiting. The client has an indwelling intravenous (IV) catheter. The client's morning laboratory results show a serum blood sodium level of 130 mEq/L and a serum blood chloride level of 92 mEq/L. Which intravenous fluids will provide free water, sodium, and chloride to the client? Select all that apply.

3. 0.45% NaCl in water solution 4. Dextrose 5% in 0.225% NaCl solution

The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The client is being treated with an intravenous hypertonic saline. The nurse determines that the treatment measures are effective when the laboratory results reveal which sodium level?

3. 140 mEq/L

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?

3. A client with a history of alcoholism

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which prescribed medication should the nurse prepare to assist in administering to the client?

3. Calcitonin (Miacalcin)

The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

3. Client with a fast respiratory rate

The nurse is monitoring the fluid balance of a client with human immunodeficiency disease (HIV). Because loss of subcutaneous adipose tissue and muscle atrophy occur in such clients, the nurse understands that which will provide a reliable indicator of fluid balance?

3. Decreased urine output and hypotension

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?

3. Hypertension

The nurse is assisting in the care of a group of clients on the nursing unit. The nurse determines that a client with which diagnosis is the one who has the least likely risk for developing third-spacing of body fluid?

3. Ischemic stroke

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

3. Muscle weakness

The nurse is caring for a client with a nasogastric tube who has prescriptions to have the tube irrigated once every 8 hours. The nurse ensures that which solution is placed in the client's room to be used for the irrigation when the client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L?

3. Normal saline

A client is at risk for developing hypocalcemia. The nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted?

3. Positive Trousseau's sign

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L. The nurse should determine that this is an expected finding if the client had which health problem?

3. Severe burn injury

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which finding should the nurse have noted?

3. The skin when pinched immediately fell back to normal when released.

A health care provider has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse preparing to administer the medication schedules the medication to be given at which time?

3. Two hours after meals

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological process?

4. "Water and electrolytes are lost in approximately the same proportion as they exist in the body."

The nurse is assisting in the care of a client who is at risk for hyponatremia. The nurse should monitor this client for which symptoms of this electrolyte imbalance?

4. Abdominal cramping

The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard on auscultation of the lungs. Which additional signs/symptoms should the nurse expect to note in this client?

4. An increase in blood pressure

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom is an indication of this electrolyte imbalance?

4. Generalized muscle weakness

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

4. Increased specific gravity of urine

The nurse is caring for a client whose magnesium level is 4 mg/dL, and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which sign or symptom is no longer present?

4. Loss of deep tendon reflexes

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mg/dL. Which sign does the nurse expect to note in the client, based on this magnesium level?

4. Loss of deep tendon reflexes

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which should the nurse observe for on the cardiac monitor as a result of this laboratory value?

4. Narrow, peaked T waves

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional signs/symptoms should the nurse expect to note in this client if hyponatremia is present?

4. Postural blood pressure changes

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by doing which? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

4. Pulling up and releasing the skin on the sternal area

The nurse is monitoring a client for hypercalcemia. Which sign/symptom would the nurse note in hypercalcemia?

4. Slight muscle weakness

Etidronate (Didronel), an antihypercalcemic medication, is prescribed for a client. Which information should the nurse reinforce when instructing the client about taking this medication?

4. Take 2 hours before meals.

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

4. The client receiving nasogastric suction

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

4. The client with diabetes mellitus

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition?

4. The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

The nurse is planning to reinforce dietary teaching about foods that are low in potassium to a client receiving a potassium-retaining diuretic. The nurse should be sure to include which food on a list of foods that have low potassium content?

4. White bread