NCLEX Fluid and Electrolytes 851 QUESTIONS & ANSWERS 2022/2023 Terms in this set (851)
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NURSING
Institution
NURSING
NCLEX Fluid and Electrolytes 851 QUESTIONS & ANSWERS
2022/2023
Terms in this set (851)
Answer: 1
What is the nurse's primary concern Rationale 1: As an adult ages, the thirst mechanism
regarding fluid & electrolytes when declines. Adding this in a pt with an altered level of
caring for an el...
NCLEX Fluid and Electrolytes 851 QUESTIONS & ANSWERS
2022/2023
Terms in this set (851)
Answer: 1
What is the nurse's primary concern Rationale 1: As an adult ages, the thirst mechanism
regarding fluid & electrolytes when declines. Adding this in a pt with an altered level of
caring for an elderly pt who is consciousness, there is an increased risk of dehydration &
intermittently confused? high serum osmolality.
1. risk of dehydration Rationale 2: The risks for kidney damage are not
2. risk of kidney damage specifically related to aging or fluid & electrolyte issues.
3. risk of stroke Rationale 3: The risk of stroke is not specifically related to
4. risk of bleeding aging or fluid & electrolyte issues.
Rationale 4: The risk of bleeding is not specifically related
to aging or fluid & electrolyte issues.
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lubiidneand ElectrolytesAnswer: 1 Study
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Report Rationale 1: Because this pt was severely burned, the fluid
within the cells is diminished, leading to an intracellular
fluid deficit.
Rationale 2: The intracellular fluid is all fluids that exist
within the cell cytoplasm & nucleus. Because this pt was
The nurse is planning care for a pt
severely burned, the fluid within the cells is diminished,
with severe burns. Which of the
leading to an intracellular fluid deficit.
following is this pt at risk for
Rationale 3: The extracellular fluid is all fluids that exist
developing?
outside the cell, including the interstitial fluid between the
1. intracellular fluid deficit
cells. Because this pt was severely burned, the fluid within
2. intracellular fluid overload
the cells is diminished, leading to an intracellular fluid
3. extracellular fluid deficit
deficit.
4. interstitial fluid deficit
Rationale 4: The extracellular fluid is all fluids that exist
outside the cell, including the interstitial fluid between the
cells. Because this pt was severely burned, the fluid within
the cells is diminished, leading to an intracellular fluid
deficit.
A pt, experiencing multisystem Answer: 1
fluid volume deficit, has the
symptoms of tachycardia, pale, Rationale 1: The internal vasoconstrictive compensatory
cool skin, & decreased urine reactions within the body are responsible for the
output. The nurse realizes these symptoms exhibited. The body naturally attempts to
findings are most likely a direct conserve fluid internally specifically for the brain & heart.
result of which of the following? Rationale 2: A diuretic would cause further fluid loss, & is
1. the body's natural compensatory contraindicated.
mechanisms Rationale 3: Rapidly infused intravenous fluids would not
2. pharmacological effects of a cause a decrease in urine output.
diuretic Rationale 4: The manifestations reported are not indicative
3. effects of rapidly infused of cardiac failure in this pt.
intravenous fluids
4. cardiac failure
,NCLEX Fluid
A pregnant pt andwith
is admitted ElectrolytesAnswer: 1 Study
excessive thirst, increased
urination, & has a medical diagnosis Rationale 1: The pt with excessive thirst, increased
of diabetes insipidus. The nurse urination & a medical diagnosis of diabetes insipidus is at
chooses which of the following risk for Imbalanced Fluid Volume due to the pt &'s excess
nursing diagnoses as most volume loss that can increase the serum levels of sodium.
appropriate? Rationale 2: Excess Fluid Volume is not an issue for pts
1. Risk for Imbalanced Fluid Volume with diabetes insipidus, especially during the early stages
2. Excess Fluid Volume of treatment.
3. Imbalanced Nutrition Rationale 3: Imbalanced Nutrition does not apply.
4. Ineffective Tissue Perfusion Rationale 4: Ineffective Tissue Perfusion does not apply
A pt recovering from surgery has Answer: 1
an indwelling urinary catheter. The Rationale 1: A urine output of less than 30 mL per hour
nurse would contact the pt's must be reported to the primary healthcare provider. This
primary healthcare provider with indicates inadequate renal perfusion, placing the pt at
which of the following 24-hour increased risk for acute renal failure & inadequate tissue
urine output volumes? perfusion. A minimum of 720 mL over a 24-hour period is
1. 600 mL desired (30 mL multiplied by 24 hours equals 720 mL per
2. 750 mL 24 hours).
3. 1000 mL
4. 1200 mL
Answer: 1
Rationale 1: Antidiuretic hormone & aldosterone levels are
commonly increased following the stress response
A pt is receiving intravenous fluids
before, during, & immediately after surgery. This increase
postoperatively following cardiac
leads to sodium & water retention. Adding more fluids
surgery. Nursing assessments
intravenously can cause a fluid volume excess & stress
should focus on which
upon the heart & circulatory system.
postoperative complication?
Rationale 2: Adding more fluids intravenously can cause a
1. fluid volume excess fluid volume excess, not fluid volume deficit, & stress
2. fluid volume deficit
upon the heart & circulatory system.
3. seizure activity
Rationale 3: Seizure activity would more commonly be
4. liver failure
associated with electrolyte imbalances.
Rationale 4: Liver failure is not anticipated related to
postoperative intravenous fluid administration.
, NCLEX Fluid and ElectrolytesAnswer: 1 Study
Rationale 1: Severe hyponatremia can lead to seizures.
A pt is diagnosed with severe
hyponatremia. The nurse realizes Seizure precautions such as a quiet environment, raised
this pt will mostly likely need which side rails, & having an oral airway at the bedside would be
of the following precautions included.
implemented? Rationale 2: Infection precautions not specifically
1. seizure indicated for a pt with hyponatremia.
2. infection Rationale 3: Neutropenic precautions not specifically
3. neutropenic indicated for a pt with hyponatremia.
4. high-risk fall Rationale 4: High-risk fall precautions not specifically
indicated for a pt with hyponatremia.
Answer: 1
A pt is diagnosed with
Rationale 1: Excess potassium loss through the kidneys is
hypokalemia. After reviewing the
often caused by such meds as corticosteroids, potassium-
pt's current medications, which of
wasting diuretics, amphotericin B, & large doses of some
the following might have antibiotics.
contributed to the pt's health
Rationale 2: Excessive sodium is lost with the use of
problem?
thiazide diuretics.
1. corticosteroid
Rationale 3: Narcotics do not typically affect electrolyte
2. thiazide diuretic balance.
narcotic
3. Rationale 4: Muscle relaxants do not typically affect
4. muscle relaxer
electrolyte balance.
Answer: 1
Rationale 1: Hyperkalemia is serum potassium level greater
A pt prescribed spironolactone is
than 5.0 mEq/L. Decreased potassium excretion is seen in
demonstrating ECG changes &
potassium-sparing diuretics such as spironolactone.
complaining of muscle weakness.
Common manifestations of hyperkalemia are muscle
The nurse realizes this pt is weakness & ECG changes.
exhibiting signs of which of the
Rationale 2: Hypokalemia is seen in non-potassium
following?
diuretics such as furosemide.
1. hyperkalemia
Rationale 3: Hypercalcemia has been associated with
2. hypokalemia
thiazide diuretics.
3. hypercalcemia
Rationale 4: Hypocalcemia is seen in pts who have
4. hypocalcemia
received many units of citrated blood & is not associated
with diuretic use.
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