NCLEX FLUID AND ELECTROLYTES REAL
EXAM QUESTIONS WITH VERIFIED
SOLUTIONS LATEST UPDATE WITH
RATIONALES
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. --CORRECT ANSWER--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
pg. 1
,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 --CORRECT ANSWER--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
pg. 2
,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). --
CORRECT ANSWER--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
pg. 3
, outcomes to the diuretic include normal heart rate, weight loss with
resolution of edema, and increased urine output.A potassium value of
5.1 mEq/L or (5.1 mmol/L) is normal. Changes in potassium levels
such as hypokalemia are side effects of furosemide, not therapeutic
effects. Although a fall in the client's BP may occur with the decrease
in body fluid, this is not the priority. Tachycardia may occur during
episodes of fluid volume excess or deficit and does not directly
indicate the medication has been effective. Weight loss, rather than
weight gain, is often the effect of Furosemide, caused by the diuresis.
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 --CORRECT
ANSWER--A. Client behavior that changes from anxious to lethargic
pg. 4
EXAM QUESTIONS WITH VERIFIED
SOLUTIONS LATEST UPDATE WITH
RATIONALES
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. --CORRECT ANSWER--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
pg. 1
,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 --CORRECT ANSWER--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
pg. 2
,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). --
CORRECT ANSWER--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
pg. 3
, outcomes to the diuretic include normal heart rate, weight loss with
resolution of edema, and increased urine output.A potassium value of
5.1 mEq/L or (5.1 mmol/L) is normal. Changes in potassium levels
such as hypokalemia are side effects of furosemide, not therapeutic
effects. Although a fall in the client's BP may occur with the decrease
in body fluid, this is not the priority. Tachycardia may occur during
episodes of fluid volume excess or deficit and does not directly
indicate the medication has been effective. Weight loss, rather than
weight gain, is often the effect of Furosemide, caused by the diuresis.
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 --CORRECT
ANSWER--A. Client behavior that changes from anxious to lethargic
pg. 4
