NCLEX Questions: Fluid & Electrolytes (Questions 1-60)

Tom is ready to be discharged from the med-surg unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury?

"If I have redness, drainage, or fever, I should call my healthcare provider" Redness, drainage, or fever are signs of infection associated with cellular injury.

Nursing interventions for a patient with hypermangesemia include administering calcium gluconate to:

Antagonize the cardiac effects of magnesium

A patient in which of the following disorders is at high risk to develop hypermagnesemia?

Renal failure

Nursing interventions for a patient with hyponatremia include

Restricting fluid intake

A 12 year old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing interventions should be included in the car of plan for the client?

Room temperature For patients with hyperthermia, reducing the room temperature may help decrease the body temperature.

Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of extracellular fluid?

Sodium

Nurse Katee is caring for Adam, a 22 year old client in a long term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting & preventing contractures?

- Maintaining correct body alignment at all times. - Using a footboard or pillows to keep feet in correct position. - Performing active & passive range of motion exercises

When monitoring the daily weight of a patient with fluid volume deficit (FVD), the nurse is aware that fluid loss may be considered when weight loss begins to exceed:

0.5 lb

The patient X is diagnosed with constipation. As a knowledgeable nurse which nursing intervention is appropriate for maintaining normal bowel movement?

Assessing dietary intake

A client with very dry mouth, skin, & mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?

Assessing urinary intake & output

Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as an 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse do?

Attempting to rule out complications before administering pain medication

Khaleesi is admitted in the hospital due to having lower than normal potassium levels in her bloodstream. Her medical history reveals vomiting & diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?

Orange juice & bananas

Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?

Positive Trousseau's sign

Josh is receiving furosemide & digoxin, which lab data would be the most important to assess in planning the care for the client?

Potassium level Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia.

A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order?

Sodium bicarbonate

Lab tests revealed that patient Z's (Na+) is 170 mEq/L. Which clinical manifestation would nurse Natty expect to assess?

Tented skin turgor & thirst This is an example of hypernatremia

When assessing a patient for electrolyte balance, the nurse is aware that etiologies for hyponatremia include

- Weight gain - Diuretic therapy - Diaphoresis

Normal serum sodium concentration ranges from

136-145 mEq/L

Normal venous blood pH ranges from:

7.31 to 7.41

Nurse Martha is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism?

Correct hand-washing technique

Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia?

Hot, flushed skin & diaphoresis

Insensible fluid losses include:

Perspiration

Lee Angela's lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you would interpret this serum chloride level as:

Within normal range

Which of the following is not an appropriate nursing intervention for a patient with hypercalcemia?

Administering calcium glucontate

Mr. McPartlin suffered abrasions & lacerations after a car accident. He was hospitalized & was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale?

The presence of infection may slow down the healing process. Infection impairs would healing. Adequate blood supply is essential for healing.

Maya who is admitted in a hospital, is scheduled to have her general checkup & physical assessment. Nurse Tim observed a reddened area over her left hip. Which should the nurse do first?

Turn the client to the right for 2 hours.

Which of the following findings would the nurse expect to assess in hypercalcemia?

Urinary calculi

Respiratory regulation of acids & bases involves

Carbon dioxide

The nurse would analyze an arterial pH of 7.46 as indicating

Alkalosis

Etiologies associated with hypocalcemia may include all of the following except:

Metastatic bone lesions

Osmotic pressure is created through the process of

Diffusion

Mang Teban has a history of COPD & has the following ABG results: partial pressure of oxygen (PO2), 55 mm Hg, & partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client's blood gas values through improved ventilation & oxygen therapy, which is the clients primary stimulus for breathing?

Low PO2

Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, & has shortness of breath & asthma. Which goal is the most important for this client?

Maintenance of adequate oxygen. For a client with asthma & infection, oxygenation is the priority

Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?

18 year old Albert who has renal disease Clients with renal disease are predisposed to hyperkalemia & should avoid foods high in potassium.

Nurse John Joseph is totaling the intake & output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, & 900 ml of half-normal saline solution & outputs 1,500 ml of urine during the shift. How many ml should the nurse document as the client's intake?

2,470

A patient with tented skin integrity, dry mucous membranes, & decreased urinary output is under nurse Mark's care. Which nursing intervention should be included the care of plan of Mark for his patient?

Administering IV & oral fluids

A 22 year old lay is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should included for reducing pain due to cellular injury?

Administering anti-inflammatory agents as prescribed

Nursing intervention for the patient with hyperphonsphatemia include encouraging intake of:

Amphogel

In the extracellular fluid, chloride is a major:

Anion

Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate?

Kayexalate The client's potassium level is elevated, therefore Kayexalate would be ordered to help reduce the potassium level

To determine if a patient's respiratory system is functioning, the nurse would assess which of the following parameters:

Arterial blood gas An ABG will indicate CO2 & O2 levels

When assessing a patient for signs of fluid overload, the nurse would expect to observe:

Bounding pulse A bounding pulse is a sign of fluid overload as more volume in the vessels causes a stronger sensation against the vessels walls.

Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid & electrolyte imbalance?

Cardiac rate & rhythm

Mrs. Dela Riva is in her first trimester of pregnancy. She has been lying all day because her OBGYN requested her to have complete bed rest. Which nursing intervention is appropriate when addressing the client's need to maintain skin integrity?

Keeping linens dry & wrinkle free

For a patient with hypomagnesemia, which of the following medications may become toxic?

Digoxin

Vick is receiving oral potassium supplements for his condition. How should the supplements be administered?

Diluted Oral potassium supplements are known to irritate GI mucosa & should be diluted.

The physician has ordered IV replacement of potassium for a patient with severe hypokalemia. The nurse would administer this:

Diluted in 100 cc over 1 hour

Which of the following conditions is associated with elevated serum chloride levels?

Eclampsia

Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?

Encouraging slow, deep breaths

Ms. Salcedo has the following ABG values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, & a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement?

Encouraging the client to cough & deep breathe The ABG results indicate respiratory acidosis requiring improved ventilation & increased oxygen to the lungs.

Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan for care for Lisa, who is experiencing urinary dribbling?

Having the client perform kegal exercises

Mang Rogelio, a 32 year old patient is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care?

Home environment evaulation

Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (SIADH)?

Hypertonic solution

Aldosterone secretion in response to fluid loss will result in which one of the following electrolyte imbalances?

Hypokalemia

Which of the following findings would the nurse expect to assess in a patient with hypokalemia?

Hyporeflexia

Dietary recommendations for a patient with a hypotonic fluid excess should include

Increased sodium intake Hypotonic fluid volume excess (FVE) involves an increase in water volume without an increase in sodium concentration

A rise in arterial pressure causes the baroreceptors & stretch receptors to signal an inhibition of the sympathetic nervous system, resulting in

Increased urine output

Geneivieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

Instituting seizure precaution to prevent injury

A 36 year old male client is about to be discharged from the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse's instructions about measures to prevent constipation.

Instructing the client to fill a 2-L bottle with water every night & drink it the next day. Adequate fluids & fiber in diet are key to preventing constipation.

Which of the following conditions is an equal decrease of extracellular fluid (ECF) solute & water volume?

Isotonic FVD