NCLEX - w16 - Fluids & Electrolytes

Question 1

A nurse is caring for a client with a serum potassium level of 3.0 mEq/L. Which of the following manifestations should the nurse monitor for?
●
A. Bounding peripheral pulses
●
B. Muscle weakness
●
C. Hyperactive deep tendon reflexes
●
D. Decreased urine output

Answer 1

B. Muscle weakness

Rationale:
Hypokalemia (low potassium) often presents with muscle weakness, fatigue, and in severe cases, cardiac arrhythmias.

Question 2

A client is receiving 0.9% normal saline intravenously at a rate of 125 mL/hr. The nurse understands that this solution is:
●
A. Isotonic
●
B. Hypotonic
●
C. Hypertonic
●
D. Colloid

Answer 2

A. Isotonic

Rationale:
0.9% normal saline is an isotonic solution, meaning it has the same concentration of solutes as blood plasma. It expands the extracellular fluid volume without causing fluid shifts between compartments.

Question 3

The nurse is caring for a client who is experiencing fluid volume overload. Which of the following assessment findings is the most concerning?
●
A. Weight gain of 2 lbs in 24 hours
●
B. Crackles heard upon auscultation of the lungs
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C. Peripheral edema +1
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D. Increased urine output

Answer 3

B. Crackles heard upon auscultation of the lungs

Rationale:
Crackles in the lungs can indicate pulmonary edema, a potentially life-threatening complication of fluid volume overload. While the other options may be present with fluid overload, they are less immediately concerning than pulmonary edema.

Question 4

A client has the following arterial blood gas (ABG) results: pH 7.32, PaCO2 50 mm Hg, HCO3- 24 mEq/L. The nurse interprets these findings as:
●
A. Metabolic acidosis
●
B. Metabolic alkalosis
●
C. Respiratory acidosis
●
D. Respiratory alkalosis

Answer 4

C. Respiratory Acidosis

Rationale:
The pH is below 7.35 indicating acidosis. The PaCO2 is elevated, indicating respiratory origin.

Question 5

The nurse is teaching a client with hypokalemia about foods high in potassium. Which food choice by the client indicates a need for further teaching?
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A. Banana
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B. Orange juice
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C. Cooked spinach
●
D. White rice

Answer 5

D. White Rice

Rationale:
White rice is relatively low in potassium. The other options are good sources of potassium.

Question 5

When caring for a client with hypernatremia, which of the following actions should the nurse prioritize?
●
A. Restrict fluid intake
●
B. Monitor for neurologic changes
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C. Encourage foods high in sodium
●
D. Administer potassium supplements

Answer 5

B. Monitor for neurologic changes

Rationale:
Hypernatremia (high sodium) can cause significant neurologic complications, including confusion, seizures, and coma. Monitoring for these changes is crucial to ensure prompt intervention

Question 6

A client with fluid volume deficit is receiving lactated Ringer’s solution. Which of the following is a priority assessment for the nurse to perform?
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A. Auscultate lung sounds
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B. Monitor urine output
●
C. Assess skin turgor
●
D. Check capillary refill

Answer 6

B. Monitor urine output

Rationale:
Monitoring urine output is essential to evaluate the effectiveness of fluid resuscitation and to assess kidney function. Adequate urine output indicates improved fluid volume status.

Question 7

A client with hypocalcemia is at increased risk for:
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A. Cardiac dysrhythmias
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B. Hypertension
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C. Constipation
●
D. Hypoglycemia

Answer 7

A. Cardiac dysrhythmias

Rationale:
Calcium plays a crucial role in cardiac muscle contraction. Hypocalcemia can lead to EKG changes and life-threatening arrhythmias

Question 8

Which of the following IV solutions would the nurse expect to be prescribed for a client with isotonic dehydration?
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A. 0.45% normal saline
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B. D5W
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C. 0.9% normal saline
●
D. 3% normal saline

Answer 8

C. 0.9% normal saline

Rationale:
Isotonic dehydration requires isotonic fluid replacement. 0.9% normal saline is an isotonic solution commonly used for this purpose.

Question 9

A nurse is assessing the IV site of a client receiving a continuous infusion of potassium chloride. Which of the following findings should the nurse report to the provider immediately?
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A. Coolness at the IV site
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B. Swelling and redness at the IV site
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C. The infusion is running at the prescribed rate
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D. The client reports mild discomfort at the IV site

Answer 9

B. Swelling and redness at the IV site

Rationale:
Swelling and redness indicate phlebitis or possible infiltration, which can have serious consequences if potassium chloride infuses into the tissues.

Question 10

A client has a serum sodium level of 150 mEq/L. The nurse recognizes that this client is experiencing:
●
A. Hyponatremia
●
B. Hypernatremia
●
C. Hypokalemia
●
D. Hyperkalemia

Answer 10

B. Hypernatremia

Rationale:
Hypernatremia is defined as a serum sodium level above 145 mEq/L.

Question 11

Which of the following laboratory values would the nurse expect to see in a client with dehydration?
●
A. Decreased hematocrit
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B. Increased urine specific gravity
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C. Decreased serum osmolality
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D. Decreased blood urea nitrogen (BUN)

Answer 11

B. Increased urine specific gravity

Rationale:
Urine specific gravity measures the concentration of urine. In dehydration, the kidneys conserve water, resulting in more concentrated urine and an elevated specific gravity.

Question 12

A client with a history of heart failure is at risk for developing which electrolyte imbalance?
●
A. Hypocalcemia
●
B. Hypomagnesemia
●
C. Hypokalemia
●
D. Hyponatremia

Answer 12

C. Hypokalemia

Rationale:
Clients with heart failure often take loop diuretics, which can lead to potassium loss and hypokalemi

Question 13

The nurse is providing care for a client who is experiencing respiratory alkalosis. Which of the following interventions is most appropriate?
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A. Administer oxygen as prescribed
●
B. Encourage the client to breathe into a paper bag
●
C. Restrict the client’s fluid intake
●
D. Administer sodium bicarbonate

Answer 13

B. Encourage the client to breathe into a paper bag

Rationale:
Breathing into a paper bag allows the client to re-breathe carbon dioxide, helping to correct the low PaCO2 levels seen in respiratory alkalosis.

Question 14

Which of the following electrolyte imbalances can result in tetany?
●
A. Hypercalcemia
●
B. Hypocalcemia
●
C. Hyperkalemia
●
D. Hypokalemia

Answer 14

B. Hypocalcemia

Rationale:
Hypocalcemia can lead to neuromuscular irritability and tetany, a condition characterized by muscle spa

Question 15

The nurse is caring for a client with a serum calcium level of 13 mg/dL. Which medication should the nurse anticipate administering?
●
A. Calcium gluconate
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B. Calcitonin
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C. Potassium chloride
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D. Magnesium sulfate

Answer 15

B. Calcitonin

Rationale:
Calcitonin helps lower serum calcium levels by inhibiting bone resorption and increasing calcium excretion by the kidneys.

Question 16

A client is admitted with severe vomiting and diarrhea. Which type of IV fluid would the nurse expect to be prescribed initially?
●
A. 0.9% normal saline
●
B. D5W
●
C. 0.45% normal saline
●
D. D5 0.45% normal saline

Answer 16

A. 0.9% normal saline

Rationale:
Isotonic solutions like 0.9% normal saline are typically used to replace fluid volume lost through vomiting and diarrhea.

Question 17

A nurse is teaching a client about the signs and symptoms of hypokalemia. Which of the following should the nurse include in the teaching?
●
A. Muscle weakness
●
B. Increased thirst
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C. Warm, flushed skin
●
D. Bounding pulse

Answer 17

A. Muscle weakness

Rationale:
Muscle weakness is a common symptom of hypokalemia, along with fatigue, cramps, and potentially cardiac arrhythmias

Question 18

A client with hyperkalemia is prescribed sodium polystyrene sulfonate (Kayexalate). The nurse understands that this medication acts by:
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A. Promoting potassium excretion in the urine
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B. Exchanging sodium for potassium in the intestines
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C. Shifting potassium into the cells
●
D. Blocking the absorption of potassium in the gut

Answer 18

B. Exchanging sodium for potassium in the intestines

Rationale:
Kayexalate is a cation-exchange resin that binds potassium in the intestines, promoting its excretion in the stool

Question 19

The nurse is caring for a client receiving a blood transfusion. The client reports chills, back pain, and difficulty breathing. What is the nurse’s priority action?
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A. Slow the transfusion rate.
●
B. Stop the transfusion immediately.
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C. Administer oxygen as prescribed.
●
D. Notify the healthcare provider.

Answer 19

B. Stop the transfusion immediately.

Rationale:
The client is exhibiting signs of a potentially severe transfusion reaction. Stopping the transfusion is the priority action to prevent further complications. The nurse should then notify the provider and administer oxygen as prescribed.

Question 20

Which of the following clients is at highest risk for developing hypermagnesemia?
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A. A client with chronic alcoholism
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B. A client with end-stage renal disease
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C. A client with diabetic ketoacidosis
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D. A client with hyperparathyroidism

Answer 20

B. A client with end-stage renal disease

Rationale:
The kidneys are the primary route of magnesium excretion. Clients with end-stage renal disease are unable to excrete magnesium effectively, putting them at risk for hypermagnesemia.

Question 21

A client with respiratory acidosis is being treated with oxygen therapy and mechanical ventilation. Which ABG result indicates that the treatment has been effective?
●
A. pH 7.35, PaCO2 45 mm Hg, HCO3- 26 mEq/L
●
B. pH 7.28, PaCO2 60 mm Hg, HCO3- 22 mEq/L
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C. pH 7.50, PaCO2 30 mm Hg, HCO3- 28 mEq/L
●
D. pH 7.42, PaCO2 55 mm Hg, HCO3- 30 mEq/L

Answer 21

A. pH 7.35, PaCO2 45 mm Hg, HCO3- 26 mEq/L

Rationale:
Effective treatment for respiratory acidosis should result in a pH within the normal range (7.35-7.45) and a decrease in PaCO2.

Question 22

Which of the following nursing interventions is appropriate for a client with hypovolemia?
●
A. Encourage fluid intake
●
B. Restrict sodium intake
●
C. Administer diuretics as prescribed
●
D. Monitor for signs of hyperkalemia

Answer 22

A. Encourage fluid intake

Rationale:
Hypovolemia (fluid volume deficit) is treated with fluid replacement to restore intravascular volume.

Question 23

A client with a nasogastric tube attached to low intermittent suction is at risk for which acid-base imbalance?
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A. Metabolic acidosis
●
B. Metabolic alkalosis
●
C. Respiratory acidosis
●
D. Respiratory alkalosis

Answer 23

B. Metabolic alkalosis

Rationale:
Gastric suctioning removes stomach acid, leading to a loss of hydrogen ions (H+) and a relative increase in bicarbonate, resulting in metabolic alkalosis.

Question 24

The nurse is caring for a client with hyperkalemia. Which of the following EKG changes is most concerning?
●
A. Tall, peaked T waves
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B. ST-segment depression
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C. Shortened QT interval
●
D. Prominent U waves

Answer 24

A. Tall, peaked T waves

Rationale:
Tall, peaked T waves are a classic EKG finding in hyperkalemia and can precede more serious dysrhythmias.

Question 25

A client is receiving intravenous magnesium sulfate for the treatment of preeclampsia. Which of the following assessments is a priority for the nurse to perform?
A. Monitor blood pressure
B. Assess deep tendon reflexes
C. Evaluate urine output
D. Auscultate lung sounds

Answer 25

B. Assess deep tendon reflexes

Rationale:
Magnesium sulfate can cause respiratory depression and decreased deep tendon reflexes. Monitoring these reflexes helps to assess for magnesium toxicity.

Question 26

A client is admitted to the hospital with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse anticipates which electrolyte imbalance?
●
A. Hypernatremia
●
B. Hyponatremia
●
C. Hyperkalemia
●
D. Hypokalemia

Answer 26

B. Hyponatremia

Rationale:
SIADH causes excessive water retention, leading to dilutional hyponatremia (low sodium).

Question 27

Which of the following clinical manifestations is associated with hypermagnesemia?
●
A. Tetany
●
B. Increased deep tendon reflexes
●
C. Hypotension
●
D. Tachycardia

Answer 27

C. Hypotension

Rationale: Hypermagnesemia can cause vasodilation and a decrease in blood pressure, leading to hypotension

Question 28

A client with metabolic acidosis has a Kussmaul’s respiratory pattern. The nurse understands that this respiratory pattern is the body’s attempt to:
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A. Conserve carbon dioxide
●
B. Decrease the pH level
●
C. Compensate for the acidosis by blowing off CO2
●
D. Increase the serum bicarbonate level

Answer 28

C. Compensate for the acidosis by blowing off CO2

Rationale:
Kussmaul’s respirations are deep, rapid breaths that are the body’s way of compensating for metabolic acidosis by expelling carbon dioxide and increasing pH.

Question 29

A client with a history of chronic obstructive pulmonary disease (COPD) is at risk for which acid-base imbalance?
●
A. Respiratory acidosis
●
B. Respiratory alkalosis
●
C. Metabolic acidosis
●
D. Metabolic alkalosis

Answer 29

A. Respiratory acidosis

Rationale:
Clients with COPD often have difficulty expelling carbon dioxide, leading to its retention and respiratory acidosis.

Question 30

Which of the following interventions is inappropriate for a client with hypervolemia?
●
A. Administer diuretics as prescribed
●
B. Restrict fluid intake
●
C. Encourage ambulation as tolerated
●
D. Administer IV fluids

Answer 30

D. Administer IV fluids

Rationale:
Administering additional IV fluids would worsen hypervolemia (fluid volume excess). The other options are appropriate interventions to manage fluid overload.

Question 31

A client is receiving 3% sodium chloride solution for the treatment of severe hyponatremia. Which of the following nursing interventions is essential?
●
A. Monitor the client’s weight daily.
●
B. Assess the client for signs of fluid overload.
●
C. Restrict the client’s potassium intake.
●
D. Encourage the client to drink plenty of fluids.

Answer 31

B. Assess the client for signs of fluid overload.

Rationale:
3% sodium chloride is a hypertonic solution that can cause fluid shifts and potentially lead to fluid overload if administered too quickly.

Question 32

A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). The nurse understands that this client is at risk for:
●
A. Hypercalcemia
●
B. Hypomagnesemia
●
C. Hyperkalemia A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). The nurse understands that this client is at risk for:
●
A. Hypercalcemia
●
B. Hypomagnesemia
●
C. Hyperkalemia
●
D. Hyponatremia

Answer 32

B. Hypomagnesemia

Rationale:
DKA often leads to electrolyte losses, including magnesium, resulting in hypomagnesemia.

Question 33

The nurse is caring for a client with hypokalemia who is receiving intravenous potassium replacement. Which of the following interventions is important to ensure the client’s safety?
●
A. Administer potassium chloride by IV push.
●
B. Ensure that potassium is diluted appropriately and administered via an infusion pump.
●
C. Monitor the client’s urine output every hour.
●
D. Encourage the client to ambulate frequently.

Answer 33

B. Ensure that potassium is diluted appropriately and administered via an infusion pump.

Rationale:
Intravenous potassium chloride should never be given by IV push. It must be diluted and administered slowly via an infusion pump to prevent cardiac complications.

Question 34

Which of the following is a potential complication of hypocalcemia?
●
A. Seizures
●
B. Constipation
●
C. Hypertension
●
D. Cardiac arrest

Answer 34

A. Seizures

Rationale:
Hypocalcemia can lead to increased neuromuscular excitability, which can manifest as seizures.

Question 35

A client has been diagnosed with metabolic alkalosis. Which of the following pH values would the nurse expect to see on an ABG analysis?
●
A. 7.25
●
B. 7.35
●
C. 7.45
●
D. 7.55

Answer 35

D. 7.55

Rationale:
Metabolic alkalosis is characterized by a pH above the normal range (7.35-7.45)

Question 36

The nurse is caring for a client with a serum magnesium level of 0.8 mEq/L. Which of the following findings would the nurse expect to see?
●
A. Lethargy
●
B. Hypotension
●
C. Hyperactive deep tendon reflexes
●
D. Bradycardia

Answer 36

C. Hyperactive deep tendon reflexes

Rationale: Hypomagnesemia can lead to neuromuscular irritability, including hyperactive reflexes

Question 37

Which of the following nursing interventions is appropriate for a client with hypernatremia?
●
A. Encourage fluids
●
B. Restrict fluid intake
●
C. Administer a hypertonic IV solution
●
D. Monitor for signs of hypokalemia

Answer 37

A. Encourage fluids

Rationale:
Increasing fluid intake helps to dilute the high sodium concentration seen in hypernatremia.

Question 38

A client with a history of heart failure is prescribed a low-sodium diet. Which food choice by the client indicates an understanding of this diet?
●
A. Grilled chicken breast
●
B. Canned soup
●
C. Deli meat
●
D. Frozen dinners

Answer 38

A. Grilled chicken breast

Rationale:
Processed and prepared foods like canned soup, deli meat, and frozen dinners are often high in sodium. Grilled chicken breast is a good low-sodium option.

Question 39

Which of the following electrolyte imbalances is associated with a positive Chvostek’s sign?
●
A. Hypercalcemia
●
B. Hypocalcemia
●
C. Hyperkalemia
●
D. Hypokalemia

Answer 39

B. Hypocalcemia

Rationale:
Chvostek’s sign, a facial muscle twitch elicited by tapping on the facial nerve, is a clinical manifestation of hypocalcemia.

Question 40

A client with metabolic acidosis is receiving sodium bicarbonate intravenously. Which of the following nursing assessments is a priority during the infusion?
●
A. Monitor the client’s respiratory rate and depth.
●
B. Assess the client’s skin turgor and mucous membranes.
●
C. Evaluate the client’s level of consciousness.
●
D. Check the client’s capillary refill time.

Answer 40

A. Monitor the client’s respiratory rate and depth.

Rationale:
Sodium bicarbonate can cause respiratory changes as the body attempts to compensate. Monitoring respiratory status is crucial to ensure adequate ventilation.

Question 41

Which of the following is a late sign of hypovolemia?
●
A. Tachycardia
●
B. Hypotension
●
C. Decreased urine output
●
D. Weakness

Answer 41

B. Hypotension

Rationale:
As hypovolemia progresses and becomes more severe, blood pressure begins to fall, resulting in hypotension.

Question 42

A client who has had prolonged vomiting is at risk for: **
●
A. Respiratory acidosis
●
B. Metabolic acidosis
●
C. Respiratory alkalosis
●
D. Metabolic alkalosis

Answer 42

D. Metabolic alkalosis

Rationale:
Loss of stomach acid from vomiting can lead to metabolic alkalosis.

Question 43

The nurse is caring for a client with hypercalcemia. Which of the following interventions is appropriate?
●
A. Encourage increased calcium intake.
●
B. Administer IV calcium gluconate.
●
C. Promote mobility and weight-bearing exercises.
●
D. Encourage fluid intake.

Answer 43

D. Encourage fluid intake.

Rationale:
Hydration helps promote calcium excretion in the urine.

Question 44

Which of the following electrolyte imbalances is most likely to cause cardiac arrest?
●
A. Hypercalcemia
●
B. Hypocalcemia
●
C. Hyperkalemia
●
D. Hypokalemia

Answer 44

C. Hyperkalemia

Rationale: Severe hyperkalemia can lead to life-threatening cardiac dysrhythmias and cardiac arrest.

Question 45

The nurse is caring for a client who has a potassium level of 6.0 mEq/L. Which of the following medications would the nurse expect to administer?
●
A. Calcium gluconate
●
B. Insulin and glucose
●
C. Sodium polystyrene sulfonate (Kayexalate)
●
D. Magnesium sulfate

Answer 45

B. Insulin and glucose

Rationale:
Insulin and glucose help shift potassium back into the cells, temporarily lowering serum potassium levels.

Question 46

A client presents with muscle cramps, tingling in the extremities, and a positive Trousseau’s sign. The nurse suspects: **
●
A. Hypernatremia
●
B. Hypokalemia
●
C. Hypercalcemia
●
D. Hypocalcemia

Answer 46

D. Hypocalcemia

Rationale:
These are classic signs of hypocalcemia, which can cause neuromuscular irritability.

Question 47

Which of the following clients is at increased risk for developing hypovolemia?
●
A. A client with excessive sweating
●
B. A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH)
●
C. A client with congestive heart failure
●
D. A client with renal failure

Answer 47

A. A client with excessive sweating

Rationale:
Excessive sweating can lead to significant fluid losses and hypovolemia

Question 48

A client is being treated for hypokalemia. Which of the following nursing diagnoses is most appropriate?
●
A. Risk for injury related to muscle weakness
●
B. Fluid volume excess related to potassium retention
●
C. Impaired gas exchange related to hypoventilation
●
D. Ineffective coping related to chronic illness

Answer 48

A. Risk for injury related to muscle weakness

Rationale:
Hypokalemia can cause muscle weakness, increasing the client’s risk for falls and injuries.

Question 49

Which of the following ABG results indicates partially compensated metabolic alkalosis?
●
A. pH 7.30, PaCO2 30 mm Hg, HCO3- 32 mEq/L
●
B. pH 7.48, PaCO2 48 mm Hg, HCO3- 30 mEq/L
●
C. pH 7.52, PaCO2 28 mm Hg, HCO3- 24 mEq/L
●
D. pH 7.40, PaCO2 40 mm Hg, HCO3- 24 mEq/L

Answer 49

B. pH 7.48, PaCO2 48 mm Hg, HCO3- 30 mEq/L

Rationale:
In partially compensated metabolic alkalosis, the pH is high (alkalotic), the HCO3- is high (the primary problem), and the PaCO2 is elevated (the respiratory system is attempting to compensate).