Fluid and Electrolytes NCLEX Questions 2024 Guaranteed Success
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Module
Fluid and Electrolytes NCLEX
Institution
Fluid And Electrolytes NCLEX
Fluid and Electrolytes NCLEX Questions 2024 Guaranteed
Success
The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding
requires immediate intervention by the nurse?
A. Client behavior that changes from anxious to lethargic
B. Deep furrows on th...
fluid and electrolytes nclex questions 2024 guaran
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Fluid and Electrolytes NCLEX Questions 2024 Guaranteed
Success
The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding
requires immediate intervention by the nurse?
A. Client behavior that changes from anxious to lethargic
B. Deep furrows on the surface of the tongue
C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched
D. Urine output of 950 mL for the past 24 hours A. Client behavior that changes from anxious to
lethargic
RATIONALE:
Immediate intervention by the nurse is required when a client's behavior changes from anxious to
lethargic. This change in mental status suggests poor cerebral blood flow and fluid shifts within the
brain cells. Immediate intervention is needed to prevent further cerebral dysfunction.Deep furrows
on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid
volume deficit, but do not indicate complications of dehydration that are immediately life-
threatening.
A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency
department (ED) by her family. She states she has been taking her diuretics for congestive heart
failure (CHF). What nursing actions are indicated at this time?
SELECT ALL THAT APPLY.
A. Place the client on bed rest.
B. Evaluate the electrolyte levels.
C. Administer the ordered diuretic.
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring. A, B, D, E
RATIONALE:
Nursing actions indicated at this time include: placing the client on bedrest and assisting the client
out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension, and applying a cardiac
monitor. Safety is required to prevent falls due to weakness from a likely fluid volume deficit and
electrolyte imbalance. The nurse should review the laboratory and diagnostic results to detect likely
loss of sodium, potassium, and magnesium secondary to diarrhea and diuretic us. Fluid volume
deficit is likely with diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially
,hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit. Monitoring
for inverted T wave or presence of U wave on the ECG as well as dysrhythmias is indicated when
hypokalemia is anticipated.Diuretics increase loss of fluids and electrolytes. The nurse would
question this order in the presence of assessment data indicating fluid loss from the diuretics and
diarrhea.
A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these
interventions does the nurse use to safely administer KCl?
SELECT ALL THAT APPLY.
A. Use a potassium infusion prepared by a registered pharmacist.
B. Assess for burning or redness during infusion.
C. Infuse at a rate of no more than 10 mEq per hour.
D. Administer only through a central venous catheter.
E. Administer by IV push only during cardiac arrest. A, B, C
RATIONALE:
Interventions to safely administer KCl to a client with hypokalemia include: using a pharmacy
prepared potassium infusion, checking the client for any burning or redness during infusion, and
infusing the IV at not more than 10 mEq per hour. The Joint Commission's National Client Safety
Goals mandates that concentrated potassium be diluted and added to IV solutions only in the
pharmacy by a registered pharmacist and that vials of concentrated potassium not be available in
client care areas. IV potassium solutions irritate veins and cause phlebitis. Assess the IV site hourly,
and ask the client whether he or she feels burning or pain at the site. The presence of pain or
burning at the insertion site may require a new intravenous to be started. A dose of KCl 5-10
mEq/hour, no more than 20 mEq/hr is recommended.Potassium may be administered by peripheral
or central vein. There is no circumstance where potassium is given by IV push.
The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of
these actions will be included in the plan of care?
SELECT ALL THAT APPLY.
A. Assess daily weights.
B. Encourage consumption of citrus fruits.
C. Weigh the client weekly.
D. Monitor serum potassium.
E. Discourage intake of spinach.
F. Monitor for bradycardia. A, B, D
, RATIONALE:
Actions for the nurse to include when caring for a client taking a loop diuretic for heart failure
include: assessing daily weights, encouraging consumption of citrus fruits, and monitoring the
client's serum potassium. High-ceiling (loop) diuretics remove excess fluid and are potassium-
depleting drugs. Consuming citrus fruit, green leafy vegetables, cantaloupe, tomato, and other food
with potassium is indicated while receiving this type of diuretic to compensate for urinary loss of
potassium.The client must be weighed at the same time each day, using the same scale and wearing
approximately the same amount of clothes. Green leafy vegetables such as spinach contain
potassium and are encouraged. The diuretic itself has no effect on the heart rate, however potassium
depletion caused by the diuretic may cause cardiac irritability with a weak and thready pulse.
The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's
potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make?
A. Heart rate
B. Blood pressure (BP)
C. Increases in edema
D. Sodium level A. Heart rate
RATIONALE:
The nurse must assess the heart rate for bradycardia related to digoxin and irritability or irregularity
related to hypokalemia. Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may
result in digoxin toxicity, even when the digoxin level is within the therapeutic range. The nurse also
assesses for GI symptoms such as diarrhea, and other symptoms of toxicity to digoxin.The BP may
decrease with low potassium level but monitoring the pulse is essential. The diuretic would reduce
edema, therefore assessing the heart rate is the priority. High serum sodium levels would not be
expected in this scenario unless fluid volume deficit is present.
Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+
pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the
medication has been effective?
A. The client's potassium level is 5.1 mEq/L (5.1 mmol/L).
B. The client's heart rate is 101 beats per minute.
C. The client is free from adventitious breath sounds.
D. The client has experienced a weight gain of 1 pound (0.5 kg). C. The client is free from
adventitious breath sounds.
RATIONALE:
The nurse recognizes that Furosemide is effective when the client is free from adventitious breath
sounds such as crackles. Other positive outcomes to the diuretic include normal heart rate, weight
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