Fluid And Electrolytes NCLEX Questions

25 July 2022
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question
A client's kidneys are retaining increased amounts of sodium. The nurse plans care, anticipating that the kidneys also are retaining greater amounts of which substances? A. Calcium and Chloride B. Chloride and bicarbonate C. Potassium and Phosphates D. Aluminum and magnesium
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Answer: B. Rationale: Sodium is a cation. With increased retention of sodium, the kidneys also increase reabsorption of chloride and bicarbonate, which are anions. Options 1 and 3 are incorrect because calcium and potassium are cations. The same is true for option 4.
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A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NGT? A. Tap water B. Sterile Water C. 0.9% Sodium Chloride D. 0.45% Sodium Chloride
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Answer: C Rationale: Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and sodium chloride are hypotonic solutions.
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The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation? A. Sustained tissue damage B. Requires Nasogastric suction C. Has a history of Addison's disease D. Is taking a potassium-retaining diuretic
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Answer: B. Rationale: The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.
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A nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? A. Tetany B. Tremors C. Areflexia D. Muscular excitability
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Answer: C Rationale: Signs of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.
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During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? A. Dehydration B. Hypokalemia C. Fluid Overload D. Hypernatremia
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Answer: A Rationale: When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.
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A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soap solution enemas until clear to a client. The UAP reports that three enemas have been administered and that the client is still passing brown liquid stool. What should the RN instruct the UAP to do? A. Administer a Fleet Enema B. Administer an oil retention enema C. Wait 30 minutes and then administer another enema D. Stop administering the enemas until the health care provider is notified
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Answer: D Rationale: Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse should call the HCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.
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The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment data would indicate to the nurse that the dehydration remains unresolved? A. An oral temperature of 98.8 F B. A urine specific gravity of 1.043 C. A urine output that is pale yellow D. A blood pressure of 120/80 mmHg
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Answer: B Rationale: The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.010 to 1.030. A temperature of 98.8Β° F is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as would the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.
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Which client is least likely to be at risk for the development of third spacing? A. The client with cirrhosis B. The client with liver failure C. The client with diabetes mellitus D. The client with chronic kidney disease
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Answer: C Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.
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A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. A. Dehydration B. HTN C. Physiological stress D. Decreased blood volume E. Decreased plasma osmolarity
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Answer: A, C, and D Rationale: Antidiuretic hormone, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality, decreased blood volume, hypotension, pain, dehydration from nausea, vomiting, or diarrhea, and stress.
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The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight Loss B. Flat neck and Hand veins C. An increase in blood pressure D. Decreased central venous pressure (CVP)
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Answer: C Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.
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The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? A. Pour into the NG tube through a syringe with the plunger removed B. Dilute with water and inject into the NG tube by putting pressure on the plunger C. Discard properly and record as output on the client's intake and output record. D. Mix with the formula and pour into the NG tube through a syringe with the plunger removed.
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Answer: A Rationale: After checking residual feeding contents, the gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water, and should not be discarded.
question
A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? A. Tetany B. Twitches C. Positive Trousseau's sign D. Loss of deep tendon reflexes
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Answer: D Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5 mg/dL is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.
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The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? A. Bradycardia B. Elevated blood pressure C. Changes in mental status D. Bilateral crackles in the lung
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Answer: C Rationale: A client with dehydration is likely to be lethargic or complaining of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.
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A nurse is planning care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. A. Ensure adequate fluid intake. B. Implement safety measures to prevent falls C. Encourage low fiber foods to prevent diarrhea. D. Instruct the client about foods that contain potassium. E. Encourage the client to obtain assistance to ambulate.
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Answer: A,B, D, and E Rationale: Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.
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A nurse is assisting in the care of a group of clients on the nursing unit. When considering effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third-spacing of fluid? A. Client with a major burn B. Client with an ischemic stroke C. Client with Laennec's cirrhosis D. Client with chronic kidney disease.
answer
Answer: B 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 pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal (GI) malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third-spacing.
question
The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.3 mg/dL. Which would be the most appropriate nursing action for this client? A. Monitor the client for dysrhythmias B. Encourage increased intake of phosphate antacids C. Discontinue any magnesium-contain medications. D. Encourage intake of foods such as ground beef, eggs, or chicken breast.
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Answer: A Rationale: The normal serum magnesium level is 1.6 to 2.6 mg/dL. Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.
question
The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route? A. The Skin B. Urinary Output C. Wound Drainage D. The gastrointestinal tract
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Answer: A Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.
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The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? A. Hypotension B. Increased heart rate C. Bounding peripheral pulses D. Shortened QT interval on electrocardiography (ECG)
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Answer: A Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.
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The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? A. Muscle twitches B. Decreased Urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine
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Answer: C Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.