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2204 Fluid & Electrolyte NCLEX Questions and
Answers (100% Correct Answers)
What is the nurse's primary concern regarding fluid & electrolytes when caring for an
elderly pt who is intermittently confused?
1. risk of dehydration
2. risk of kidney damage
3. risk of stroke
4. risk of bleeding
Ans: Answer: 1
Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with
an altered level of consciousness, there is an increased risk of dehydration & high
serum osmolality.
Rationale 2: The risks for kidney damage are not specifically related to aging or fluid
& electrolyte issues.
Rationale 3: The risk of stroke is not specifically related to aging or fluid &
electrolyte issues.
Rationale 4: The risk of bleeding is not specifically related to aging or fluid &
electrolyte issues.
The nurse is planning care for a pt with severe burns. Which of the following is this
pt at risk for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit
Ans: Answer: 1
Rationale 1: Because this pt was severely burned, the fluid within the cells is
diminished, leading to an intracellular fluid deficit.
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Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm &
nucleus. Because this pt was severely burned, the fluid within the cells is diminished,
leading to an intracellular fluid deficit.
Rationale 3: 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.
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 fluid volume deficit, has the symptoms of
tachycardia, pale, cool skin, & decreased urine output. The nurse realizes these
findings are most likely a direct result of which of the following?
1. the body's natural compensatory mechanisms
2. pharmacological effects of a diuretic
3. effects of rapidly infused intravenous fluids
4. cardiac failure
Ans: Answer: 1
Rationale 1: The internal vasoconstrictive compensatory reactions within the body
are responsible for the symptoms exhibited. The body naturally attempts to conserve
fluid internally specifically for the brain & heart.
Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine
output.
Rationale 4: The manifestations reported are not indicative of cardiac failure in this
pt.
A pregnant pt is admitted with excessive thirst, increased urination, & has a medical
diagnosis of diabetes insipidus. The nurse chooses which of the following nursing
diagnoses as most appropriate?
1. Risk for Imbalanced Fluid Volume
2. Excess Fluid Volume
3. Imbalanced Nutrition
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4. Ineffective Tissue Perfusion
Ans: Answer: 1
Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of
diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess
volume loss that can increase the serum levels of sodium.
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus,
especially during the early stages of treatment.
Rationale 3: Imbalanced Nutrition does not apply.
Rationale 4: Ineffective Tissue Perfusion does not apply
A pt recovering from surgery has an indwelling urinary catheter. The nurse would
contact the pt's primary healthcare provider with which of the following 24-hour
urine output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL
Ans: Answer: 1
Rationale 1: A urine output of less than 30 mL per hour must be reported to the
primary healthcare provider. This indicates inadequate renal perfusion, placing the
pt at increased risk for acute renal failure & inadequate tissue perfusion. A minimum
of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals 720
mL per 24 hours).
A pt is receiving intravenous fluids postoperatively following cardiac surgery.
Nursing assessments should focus on which postoperative complication?
1. fluid volume excess
2. fluid volume deficit
3. seizure activity
4. liver failure
Ans: Answer: 1
Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased
following the stress response before, during, & immediately after surgery. This
2204 Fluid & Electrolyte NCLEX Questions and
Answers (100% Correct Answers)
What is the nurse's primary concern regarding fluid & electrolytes when caring for an
elderly pt who is intermittently confused?
1. risk of dehydration
2. risk of kidney damage
3. risk of stroke
4. risk of bleeding
Ans: Answer: 1
Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with
an altered level of consciousness, there is an increased risk of dehydration & high
serum osmolality.
Rationale 2: The risks for kidney damage are not specifically related to aging or fluid
& electrolyte issues.
Rationale 3: The risk of stroke is not specifically related to aging or fluid &
electrolyte issues.
Rationale 4: The risk of bleeding is not specifically related to aging or fluid &
electrolyte issues.
The nurse is planning care for a pt with severe burns. Which of the following is this
pt at risk for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit
Ans: Answer: 1
Rationale 1: Because this pt was severely burned, the fluid within the cells is
diminished, leading to an intracellular fluid deficit.
,2 Inquire through: | Professional | Confidential Support
Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm &
nucleus. Because this pt was severely burned, the fluid within the cells is diminished,
leading to an intracellular fluid deficit.
Rationale 3: 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.
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 fluid volume deficit, has the symptoms of
tachycardia, pale, cool skin, & decreased urine output. The nurse realizes these
findings are most likely a direct result of which of the following?
1. the body's natural compensatory mechanisms
2. pharmacological effects of a diuretic
3. effects of rapidly infused intravenous fluids
4. cardiac failure
Ans: Answer: 1
Rationale 1: The internal vasoconstrictive compensatory reactions within the body
are responsible for the symptoms exhibited. The body naturally attempts to conserve
fluid internally specifically for the brain & heart.
Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine
output.
Rationale 4: The manifestations reported are not indicative of cardiac failure in this
pt.
A pregnant pt is admitted with excessive thirst, increased urination, & has a medical
diagnosis of diabetes insipidus. The nurse chooses which of the following nursing
diagnoses as most appropriate?
1. Risk for Imbalanced Fluid Volume
2. Excess Fluid Volume
3. Imbalanced Nutrition
, 3 Inquire through: | Professional | Confidential Support
4. Ineffective Tissue Perfusion
Ans: Answer: 1
Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of
diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess
volume loss that can increase the serum levels of sodium.
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus,
especially during the early stages of treatment.
Rationale 3: Imbalanced Nutrition does not apply.
Rationale 4: Ineffective Tissue Perfusion does not apply
A pt recovering from surgery has an indwelling urinary catheter. The nurse would
contact the pt's primary healthcare provider with which of the following 24-hour
urine output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL
Ans: Answer: 1
Rationale 1: A urine output of less than 30 mL per hour must be reported to the
primary healthcare provider. This indicates inadequate renal perfusion, placing the
pt at increased risk for acute renal failure & inadequate tissue perfusion. A minimum
of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals 720
mL per 24 hours).
A pt is receiving intravenous fluids postoperatively following cardiac surgery.
Nursing assessments should focus on which postoperative complication?
1. fluid volume excess
2. fluid volume deficit
3. seizure activity
4. liver failure
Ans: Answer: 1
Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased
following the stress response before, during, & immediately after surgery. This
