Fluids & Electrolytes (saunders NCLEX book)

Question 1

A registered nurse (RN) is discussing the overall fluid balance of an assigned client. The RN calculates 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 of the following areas?

1. Nasogastric tube and wound drain
2. Foley catheter and nasogastric tube
3. Wound drain and skin
4. Skin and lungs

Answer 1

Skin and lungs
**Rationale: Insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. They occur on a daily basis without the client’s awareness. Sensible losses are those that are measurable and include wound drainage, gastrointestinal tract losses, and urine output.
Test-Taking Strategy: Focus on the subject, insensible fluid losses. The key point to recall is that insensible fluid losses cannot be measured. This will direct you to the correct option. Review sensible and insensible fluid losses if you had difficulty with this question.

Question 2

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

1. Laënnec’s cirrhosis
2. Ischemic stroke
3. Major burn
4. Renal failure

Answer 2

Ischemic stroke
**Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third-spacing include the pleural and peritoneal cavities and the pericardial sac. Clients at high risk for third-spacing include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The client who suffered a stroke is not at risk for third-spacing.
Test-Taking Strategy: Note the strategic words “least amount of risk,” and focus on the subject, third-spacing of fluids. Think about the pathophysiology associated with each disorder to direct you to option 2. Review the concept of third-spacing if you had difficulty with this question.

Question 3

A 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 of the following diagnoses and is most at risk for fluid volume deficit?

1. Ileostomy
2. Hypertension
3. Congestive heart failure
4. Acute renal failure

Answer 3

Ileostomy
**Rationale: The client with ileostomy is at risk for fluid volume deficit due to increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or renal failure are at risk for fluid volume excess. Hypertension is unrelated to the subject of the question.
Test-Taking Strategy: The strategic words in the question are “fluid volume deficit.” Read each option, considering the fluid imbalance that can occur in each. Eliminate options 3 and 4 first because these clients would be more likely to retain fluid than to lose it. Choose correctly between the remaining two options considering the liquid nature of ileostomy drainage. If you had difficulty with this question, review the causes of fluid volume deficit.

Question 4

An older adult client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which of the following manifestations that correlates with this client’s fluid imbalance?

1. Flat neck veins
2. Lung crackles
3. Increased blood pressure
4. Decreased pulse

Answer 4

Flat neck veins
**Rationale: A client with dehydration has a fluid volume deficit, which can be reflected by flat neck veins. Other findings are increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The manifestations noted in options 2, 3, and 4 indicate fluid volume excess.
Test-Taking Strategy: Focus on the client’s diagnosis. Next, discriminate between the signs of fluid volume deficit and the signs of fluid volume excess. Recalling that the intravascular compartment is depleted with fluid volume deficit will help you choose correctly. If you had difficulty with this question, review the characteristics of fluid volume deficit.

Question 5

A nurse is administering a dose of a prescribed diuretic to an assigned client. The nurse would plan to monitor the client for hypokalemia as a side effect of therapy if the client were receiving which of the following medications?

1. Spironolactone (Aldactone)
2. Bumetanide (Bumex)
3. Triamterene (Dyrenium)
4. Amiloride HCl (Midamor)

Answer 5

Bumetanide (Bumex)
**Rationale: Bumetanide (Bumex) is a loop diuretic that places the client at risk for hypokalemia. The nurse would monitor this client carefully for signs of hypokalemia, monitor serum potassium levels, and encourage intake of high-potassium foods. The other medications listed are potassium-sparing diuretics.
Test-Taking Strategy: Focus on the subject, hypokalemia, as a side effect. Recall the classifications of the diuretics in the options. Remember that bumetanide is a loop diuretic that places the client at risk for hypokalemia. Review these medications if you had difficulty with this question.

Question 6

A nurse is assisting in the care of a client who is at risk for hyponatremia. The nurse would monitor this client for which of the following manifestations of this electrolyte imbalance?

1. Slow pulse rate
2. High blood pressure
3. Flaccid muscles
4. Abdominal cramping

Answer 6

Abdominal cramping
**Rationale: Signs of hyponatremia include rapid, thready pulse; postural blood pressure changes; weakness; abdominal cramping; poor skin turgor; muscle twitching and seizures; mental confusion; and apprehension.
Test-Taking Strategy: Focus on the subject, the manifestations of hyponatremia. Remember that abdominal cramping is a manifestation of hyponatremia. If you had difficulty with this question, review the manifestations of hyponatremia.

Question 7

A nurse is planning to reinforce dietary teaching about foods that are low in potassium to a client receiving a potassium-sparing diuretic. The nurse would be sure to include which of the following on a list of foods that have a low potassium content?

1. Spinach
2. Avocado
3. Fresh pork
4. White bread

Answer 7

White bread
**Rationale: A slice of white bread provides 27 mg of potassium. Raw spinach (3 1/2 ounces) provides 470 mg of potassium. One avocado provides 1097 mg of potassium, and 4 ounces of pork provides 525 mg of potassium.
Test-Taking Strategy: Focus on the subject, the food low in potassium content. Use knowledge about this subject and recall that fruits, vegetables, and pork are high in potassium. Learn the foods that are high and low in potassium content if you had difficulty with this question.

Question 8

A 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?

1. A client with a new burn injury
2. A client with Cushing’s syndrome
3. A client with ulcerative colitis
4. A client who has a history of long-term laxative abuse

Answer 8

A client with a new burn injury
**Rationale: Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. Clients with Cushing’s syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.
Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate options 3 and 4 first because they reflect gastrointestinal losses. Remembering that cell destruction causes potassium shifts will direct you to the correct option. Also recall that Cushing’s syndrome presents a risk for hypokalemia and that Addison’s disease presents a risk for hyperkalemia. If you had difficulty with this question, review the risk factors associated with hyperkalemia.

Question 9

A nurse is monitoring a client for hypercalcemia. Which of the following would the nurse note in hypercalcemia?

1. Slight muscle weakness
2. Tingling sensations
3. Hyperactive reflexes
4. Muscle cramps

Answer 9

Slight muscle weakness
**Rationale: Hypotonia (slight muscle weakness) is seen in hypercalcemia. Signs of hypocalcemia include tingling sensations, hyperactive reflexes, and a positive Trousseau’s or Chvostek’s sign. Other signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety.
Test-Taking Strategy: Use the process of elimination, noting that all of the incorrect options are comparable or alike in that they reflect hyperactivity of the neuromuscular system. The option that is different is option 1. Review the findings noted in hypercalcemia and hypocalcemia if you had difficulty with this question.

Question 10

A nurse is caring for a client with Paget’s disease who has an elevated serum calcium level of 12.3 mEq/L. The nurse checks to see that which of the following medications is available in the stock medication supply area for possible use to reverse this elevation?

1. Calcium gluconate
2. Calcium chloride
3. Calcitonin (Calcimar)
4. Vitamin D

Answer 10

Calcitonin (Calcimar)
**Rationale: The normal serum calcium level is 4.5 to 5.5 mEq/L or 9 to 11 mg/dL. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. In hypercalcemia, large doses of vitamin D should be avoided. Calcium gluconate and calcium chloride would be used to treat tetany that results from acute hypocalcemia.
Test-Taking Strategy: Eliminate options 1 and 2 first, recalling that they are used to treat hypocalcemia. To select between the remaining options, remember that excessive vitamin D is a causative factor of hypercalcemia. If you had difficulty with this question, review the treatment for hypercalcemia.