NCLEX: FLUIDS AND ELECTROLYTES
1. A client with hypoparathyroidism complains of numbness
and tingling in his fingers and around the mouth. The
nurse would assess for what electrolyte imbalance?
a. Hyponatremia
b. Hypocalcemia
c. Hyperkalemia
d. Hypermagnesemia
Rationale: Hypoparathyroidism can cause low serum calcium
levels. Numbness and tingling in extremities and in the
circumoral area around the mouth are the hallmark signs of
hypocalcemia. Normal calcium level is 9 to 11 mg/dl.
2. The nurse evaluates which of the following clients to be at
risk for developing hypernatremia?
a. 50-year-old with pneumonia, diaphoresis, and
high fevers
b. 62-year-old with congestive heart failure taking
loop diuretics
c. 39-year-old with diarrhea and vomiting
d. 60-year-old with lung cancer and syndrome of
inappropriate antidiuretic hormone (SIADH)
Rationale: Diaphoresis and a high fever can lead to free water
loss through the skin, resulting in hypernatremia. Loop
diuretics are more likely to result in a hypovolemic
hyponatremia. Diarrhea and vomiting cause both sodium and
water losses. Clients with syndrome of inappropriate
antidiuretic hormone (SIADH) have hyponatremia, due to
increased water reabsorption in the renal tubules.
3. A client is admitted with diabetic ketoacidosis who, with
treatment, has a normal blood glucose, pH, and serum
osmolality. During assessment, the client complains of
weakness in the legs. Which of the following is a priority
nursing intervention?
a. Request a physical therapy consult from the physician
b. Ensure the client is safe from falls and check the most
recent potassium level
c. Allow uninterrupted rest periods throughout the day
d. Encourage the client to increase intake of dairy
products and green leafy vegetables.
Rationale: In the treatment of diabetic ketoacidosis, the blood
sugar is lowered, the pH is corrected, and potassium moves
back into the cells, resulting in low serum potassium. Client
safety and the correction of low potassium levels are a priority.
The weakness in the legs is a clinical manifestation of the
hypokalemia. Dairy products and green, leafy vegetables are a
source of calcium.
4. A client with a potassium level of 5.5 mEq/L is to receive
sodium polystyrene sulfonate (Kayexalate) orally. After
administering the drug, the priority nursing action is to
monitor:
a. Urine output.
b. Blood pressure.
c. Bowel movements.
d. ECG for tall, peaked T waves
Rationale: Kayexalate causes potassium to be exchanged for
sodium in the intestines and excreted through bowel
movements. If client does not have stools, the drug cannot
work properly. Blood pressure and urine output are not of
primary importance. The nurse would already expect changes
in T waves with hyperkalemia. Normal serum potassium is 3.5
to 5.5 mEq/L.
5. The nurse is caring for a client who has been in good
health up to the present and is admitted with cellulitis of
the hand. The client's serum potassium level was 4.5
mEq/L yesterday. Today the level is 7 mEq/L. Which of
the following is the next appropriate nursing action?
a. Call the physician and report results
b. Question the results and redraw the specimen
c. Encourage the client to increase the intake of
bananas
d. Initiate seizure precautions
Rationale: A client who has been in good health up to the
present is admitted for cellulitis of the hands. When the serum
potassium goes from 4.5 mEq/L to 7.0 mEq/L with no risk
factors for hyperkalemia, false high results should be
suspected because of hemolysis of the specimen. The
physician would likely question results as well. Bananas are a
food high in potassium. Seizures are not a clinical
manifestation of hyperkalemia.
6. A client is receiving an intravenous magnesium infusion to
correct a serum level of 1.4 mEq/L. Which of the following
assessments would alert the nurse to immediately stop
the infusion?
a. Absent patellar reflex
b. Diarrhea
c. Premature ventricular contractions
d. Increase in blood pressure
Rationale: An intravenous magnesium infusion may be used to
treat a low serum magnesium level. Normal serum magnesium
is 1.5 to 2.5 mEq/L. Clinical manifestations of
hypermagnesemia are the result of depressed neuromuscular
transmission. Absent reflexes indicate a magnesium level
around 7 mEq/L. Diarrhea and PVCs are not clinical
manifestations of high magnesium levels. Hypermagnesemia
causes hypotension.
7. A client with chronic renal failure reports a 10 pound
weight loss over 3 months and has had difficulty taking
 calcium supplements. The total calcium is 6.9 mg/dl.
Which of the following would be the first nursing action?
a. Assess for depressed deep tendon reflexes
b. Call the physician to report calcium level
c. Place an intravenous catheter in anticipation of
administering calcium gluconate
d. Check to see if a serum albumin level is available
Rationale: A client with chronic renal failure who reports a 10
pound weight loss over 3 months and has difficulty taking
calcium supplements is poorly nourished and likely to have
hypoalbuminemia. A drop in serum albumin will result in a false
low total calcium level. Placing an IV is not a priority action.
Depressed reflexes are a sign of hypercalcemia. Normal
serum calcium is 9 to 11 mg/dl.
8. A client with heart failure is complaining of nausea. The
client has received IV furosemide (Lasix), and the urine
output has been 2500 ml over the past 12 hours. The
client's home drugs include metoprolol (Lopressor),
digoxin (Lanoxin), furosemide, and multivitamins. Which of
the following are the appropriate nursing actions before
administering the digoxin? Select all that apply.
a. Administer an antiemetic prior to giving the digoxin
b. Encourage the client to increase fluid intake
c. Call the physician
d. Report the urine output
e. Report indications of nausea
Rationale: Potassium is lost during diuresis with a loop diuretic
such as furosemide (Lasix). Hypokalemia can cause digitalis
toxicity, which often results in nausea. The physician should be
notified, and digoxin should be held until potassium levels and
digoxin levels are checked. Peaked T waves and widened
QRS are manifestations of hyperkalemia.
9. The nurse is caring for a bedridden client admitted with
multiple myeloma and a serum calcium level of 13 mg/dl.
Which of the following is the most appropriate nursing
action?
a. Provide passive ROM exercises and encourage fluid
intake
b. Teach the client to increase intake of whole grains
and nuts
c. Place a tracheostomy tray at the bedside
d. Administer calcium gluconate IM as ordered
Rationale: A client who has a serum calcium of 13 mg/dl has
hypercalcemia. Normal serum calcium is 9 to 11 mg/dl. Fluid
intake promotes renal excretion of excess calcium. ROM
exercises promote reabsorption of calcium into bone. Placing a
tracheostomy at the bedside is a nursing intervention for
hypocalcemia. Although calcium gluconate may be
administered in hypocalcemia, it is never administered IM.
10. An older adult client admitted with heart failure and a
sodium level of 113 mEq/L is behaving aggressively
toward staff and does not recognize family members.
When the family expresses concern about the client's
behavior, the nurse would respond most appropriately by
stating
a. "The client may be suffering from dementia, and the
hospitalization has worsened the confusion."
b. "Most older adults get confused in the hospital."
c. "The sodium level is low, and the confusion will
resolve as the levels normalize."
d. "The sodium level is high and the behavior is a result
of dehydration."
Rationale: Normal serum level is 135 to 145 mEq/L.
Neurological symptoms occur when sodium levels fall
below 120 mEq/L. The confusion is an acute condition that
will go away as the sodium levels normalize. Dementia is
an irreversible condition.
11. A client with a serum sodium of 115 mEq/L has been
receiving 3% NS at 50 ml/hr for 16 hours. This morning
the client feels tired and short of breath. Which of the
following interventions is a priority?
a. Turn down the infusion
b. Check the latest sodium level
c. Assess for signs of fluid overload
d. Place a call to the physician
Rationale: A complication of hypertonic sodium solution
administration is fluid overload. While turning down the
infusion, checking the latest sodium level, and notifying the
physician may all be reasonable, the priority intervention is to
assess for manifestations of fluid overload. Assessment is
always the priority to determine what action to take next.
12. A client with chronic renal failure receiving dialysis
complains of frequent constipation. When performing
discharge teaching, which over-the-counter products
should the nurse instruct the client to avoid at home?
a. Bisacodyl (Dulcolax) suppository
b. Fiber supplements
c. Docusate sodium
d. Milk of magnesia
Rationale: Milk of magnesia contains magnesium, an
electrolyte that is excreted by kidneys. Clients with renal failure
are at risk for hypermagnesemia since their bodies cannot
excrete the excess magnesium. The client should avoid
magnesium-containing laxatives.
13. A client is receiving intravenous potassium
supplementation in addition to maintenance fluids. The
urine output has been 120 ml every 8 hours for the past
16 hours and the next dose is due. Before administering
 the next potassium dose, which of the following is the
priority nursing action?
a. Encourage the client to increase fluid intake
b. Administer the dose as ordered
c. Draw a potassium level and administer the dose if the
level is low or normal
d. Notify the physician of the urine output and hold the
dose
Rationale: Urine output is an indication of renal function.
Normal urine output is at least 30 ml/hour. Clients with
impaired renal function are at risk for hyperkalemia. Initiating a
lab draw requires a physician order.
14. The nurse should monitor for clinical manifestations of
hypophosphatemia in which of the following clients?
a. A client with osteoporosis taking vitamin D and
calcium supplements
b. A client who is alcoholic receiving total parenteral
nutrition
c. A client with chronic renal failure awaiting the first
dialysis run
d. A client with hypoparathyroidism secondary to thyroid
surgery
Rationale: A client with osteoporosis taking vitamin and
calcium supplements, a client with chronic renal failure
awaiting dialysis, and a client with hypoparathyroidism
secondary to thyroid surgery are at risk for
hyperphosphatemia. Alcoholics and clients receiving TPN are
at risk for low phosphorus levels, due to poor intestinal
absorption and shifting of phosphorus into cells along with
insulin and glucose.
15. A client admitted with squamous cell carcinoma of the
lung has a serum calcium level of 14 mg/dl. The nurse
should instruct the client to avoid which of the following
foods upon discharge? Select all that apply.
a. Eggs
b. Broccoli
c. Organ meats
d. Nuts
e. Canned salmon
Rationale: Fish, eggs, and organ meats are high in
phosphorus. Broccoli, nuts, and canned salmon are high in
calcium. Clients with lung or breast cancer often have elevated
calcium levels due to tumor-induced hyperparathyroidism.
16. A client with pancreatitis has been receiving potassium
supplementation for four days since being admitted with a
serum potassium of 3.0 mEq/L. Today the potassium level
is 3.1 mEq/L. Which of the following laboratory values
should the nurse check before notifying the physician of
the client's failure to respond to treatment?
a. Sodium
b. Phosphorus
c. Calcium
d. Magnesium
Rationale: Low serum magnesium levels can inhibit potassium
ions from crossing cell membranes, resulting in potassium loss
through the urine. Generally, low magnesium levels must be
corrected before potassium replacement is effective.
17. The nurse should include which of the following
instructions to assist in controlling phosphorus levels for a
client in renal failure?
a. Increase intake of dairy products and nuts
b. Take aluminum-based antacids such as aluminum
hydroxide (Amphojel) with or after meals
c. Reduce intake of chocolate, meats, and whole grains
d. Avoid calcium supplements
Rationale: Aluminum-based antacids are often prescribed in
the treatment of renal failure to bind with phosphate and
increase elimination through the GI tract. Dairy products and
nuts are foods high in phosphorus. Chocolate, meats, and
whole grains are foods high in magnesium. Clients with renal
failure often require calcium supplements as a result of poor
vitamin D metabolism and in order to prevent
hyperphosphatemia.
18. A client with pneumonia presents with the following arterial
blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28
mEq/L, and PO2 of 45, which of the following is the most
appropriate nursing intervention?
a. Administer a sedative
b. Place client in left lateral position
c. Place client in high-Fowler's position
d. Assist the client to breathe into a paper bag
Rationale: The client with a pH of 7.28, PaCO2 of 74, HCO3 of
28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis.
Placing the client in high-Fowler's position will facilitate the
expansion of the lungs and help the client blow off the excess
CO2. Sedatives would impede respirations. The question does
not indicate which is the affected lung, so left lateral position
would not be a first choice. Breathing into a paper bag will
cause the PCO2 to rise higher.
19. A client with COPD feels short of breath after walking to
the bathroom on 2 liters of oxygen nasal cannula. The
morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of
35 mEq/L, O2 at 88% on 2 liters. Which of the following
should be the nurse's first intervention?
a. Call the physician and report the change in client's
condition
b. Turn the client's O2 up to 4 liters nasal cannula
 c. Encourage the client to sit down and to take deep
breaths
d. Encourage the client to rest and to use pursed-lip
breathing technique
Rationale: Clients with COPD, especially those who are in a
chronic compensated respiratory acidosis, are very sensitive to
changes in O2 flow, because hypoxemia rather than high CO2
levels stimulates respirations. Deep breaths are not helpful,
because clients with COPD have difficulty with air trapping in
alveoli. There is no need to call the physician since this client
is presently most likely at baseline.
20. A client who had a recent surgery has been vomiting and
becomes dizzy while standing up to go to the bathroom.
After assisting the client back to bed, the nurse notes that
the blood pressure is 55/30 and the pulse is 140. The
nurse hangs which of the following IV fluids to correct this
condition?
a. D5.45 NS at 50 ml/hr
b. 0.9 NS at an open rate
c. D5W at 125 ml/hr
d. 0.45 NS at open rate
Rationale: A client who recently had surgery, is vomiting,
becomes dizzy when standing up, has a blood pressure of
55/30, and has a pulse of 140 is hypovolemic and requires
plasma volume expansion. Isotonic fluids such as 0.9 NS will
expand volume. Hypotonic fluids such as 0.45 NS will leave
the intravascular space. D5W will metabolize into free water
and leave the intravascular space. D5.45 NS is a good
maintenance fluid but a rate of 50 ml per hour is not sufficient
to expand the vascular volume quickly.
21. A client with renal failure enters the emergency room after
skipping three dialysis treatments to visit family out of
town. Which set of ABGs would indicate to the nurse that
the client is in a state of metabolic acidosis?
a. PH of 7.43, PCO2 of 36, HCO3 of 26
b. PH of 7.41, PCO2 of 49, HCO3 of 30
c. PH of 7.33, PCO2 of 35, HCO3 of 17
d. PH of 7.25, PCO2 of 56, HCO3 of 28
Rationale: A pH of 7.33, PCO2 of 35, and HCO3 of 17 and a
pH of 7.25, PCO2 of 56, and HCO3 of 28 both indicate
acidosis. The pH of 7.25 is a respiratory acidosis. A pH of 7.41,
PCO2 of 49, and HCO3 of 30 is a compensated metabolic
alkalosis. A pH of 7.43, PCO2 of 36, and HCO3 of 26 is
normal.
22.