Fundamentals of Nursing: Fluid and
Electrolyte Imbalance Questions and
Answers (Latest Update 2024)
An older adult client is admitted with dehydration. Which
nursing assessment data identify that the client is at risk for
falling?
A. Dry oral mucous membranes
B. Orthostatic blood pressure changes
C. Pulse rate of 72 beats/min and bounding
D. Serum potassium level of 4.0 mEq/L - Correct Answer
✅B
Blood pressure decreases when changing positions. The client
may not have sufficient blood flow to the brain, causing
sensations of light-headedness and dizziness. This problem
increases the risk for falling, especially in older adults.
Assessment of oral mucous membranes and the pulse rate
can detect symptoms of dehydration, but these are not the
best ways to assess for a fall risk. Checking serum potassium
does not assess for fall risk.
A client has a low serum potassium level and is ordered a
dose of parenteral potassium chloride (KCl). How does a
nurse safely administer KCl to the client?
A. Administers 5 mEq intramuscularly
,Fundamentals of Nursing: Fluid and
Electrolyte Imbalance Questions and
Answers (Latest Update 2024)
B. Dilutes 200 mEq in 1 liter of normal saline and infuses at
100 mL/hr
C. Infuses 10 mEq over a 1-hour period
D. Pushes 5 mEq through a central access line - Correct
Answer ✅C
A dose of KCl 10 mEq given over 1 hour is appropriate for this
client. A dose of KCl 200 mEq in 1 liter of normal saline
infused at 100 mL/hr is too concentrated and can cause
injury. Potassium is a severe tissue irritant and is never given
by the intramuscular or subcutaneous route. Because rapid
infusion of potassium can cause cardiac arrest, potassium is
not administered through central lines.
A client is being monitored for daily weights. The night nurse
asks the nursing assistant for the morning weight, and the
assistant replies, "She was sleeping so well, I didn't want to
wake her to get her weight." How does the nurse respond?
A. "Fast thinking! She really needs to rest after the night she
had."
B. "Get the information now, or I'll report you for not doing
your job."
,Fundamentals of Nursing: Fluid and
Electrolyte Imbalance Questions and
Answers (Latest Update 2024)
C. "Never mind—I will do it myself."
D. "Weigh her now. We need her weight daily, at the same
time." - Correct Answer ✅D
The nurse should educate the nursing assistant as to why
obtaining the client's weight at the same time each day is
important. Although the nursing assistant may be hesitant to
wake the client, assessing the client's fluid balance is more
important. The responses that the client needed the rest,
telling the nursing assistant to get the information now or
she'll be reported, or that the nurse will get the information
herself do not demonstrate good leadership. The assistant
needs to understand the rationale for waking and weighing
the client. She should not be dismissed and belittled by the
nurse.
The nurse instructs an older adult client to increase intake of
dietary potassium when the client is prescribed which
classification of drugs?
A. Alpha antagonists
B. Beta blockers
C. Corticosteroids
, Fundamentals of Nursing: Fluid and
Electrolyte Imbalance Questions and
Answers (Latest Update 2024)
D. High-ceiling (loop) diuretics - Correct Answer ✅D
High-ceiling (loop) diuretics are potassium-depleting drugs.
The client should increase intake of dietary potassium to
compensate for this depletion. Alpha antagonists, beta
blockers, and corticosteroids are not potassium-depleting
drugs.
The nurse is instructing a client who is being discharged with
a diagnosis of congestive heart failure (CHF). Which client
statement indicates a correct understanding of CHF?
A. "I can gain 2 pounds of water a day without risk."
B. "I should call my provider if I gain more than 1 pound a
week."
C. "Weighing myself daily can determine if my caloric intake
is adequate."
D. "Weighing myself daily can reveal increased fluid
retention." - Correct Answer ✅D
Fluid retention may not be visible. Rapid weight gain is the
best indicator of fluid retention and overload. Each pound of
weight gained (after the first half-pound) equates to 500 mL
of retained water. The client should be weighed at the same
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