ELITE COMPREHENSIVE
CRITICAL CARE FLUIDS AND ELECTROLYTES EXAM
IV Therapy, Dehydration, Overload and Emergency
Management
FINAL SPRING EXAM|| QUESTIONS AND ANSWERS||
GRADE A+
A client with diarrhea for 3 days and inability to eat or drink well is brought to the
emergency department (ED) by her family. She states she has been taking her diuretics
for congestive heart failure (CHF). What nursing actions are indicated at this time?
SELECT ALL THAT APPLY.
A. Place the client on bed rest.
B. Evaluate the electrolyte levels.
C. Administer the ordered diuretic.
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring.
✓ A, B, D, E
✓ RATIONALE:
✓ Nursing actions indicated at this time include: placing the client on
bedrest and assisting the client out of bed, evaluating electrolyte
levels, assessing for orthostatic hypotension, and applying a cardiac
1
Page
monitor. Safety is required to prevent falls due to weakness from a
, likely fluid volume deficit and electrolyte imbalance. The nurse should
review the laboratory and diagnostic results to detect likely loss of
sodium, potassium, and magnesium secondary to diarrhea and
diuretic us. Fluid volume deficit is likely with diarrhea and diuretic use
and leads to fluid and electrolyte imbalances, especially hypokalemia.
Assessing for orthostatic changes will confirm presence of volume
deficit. Monitoring for inverted T wave or presence of U wave on the
ECG as well as dysrhythmias is indicated when hypokalemia is
anticipated.Diuretics increase loss of fluids and electrolytes. The
nurse would question this order in the presence of assessment data
indicating fluid loss from the diuretics and diarrhea.
A client with hypokalemia has a prescription for parenteral potassium chloride (KCl).
Which of these interventions does the nurse use to safely administer KCl?
SELECT ALL THAT APPLY.
A. Use a potassium infusion prepared by a registered pharmacist.
B. Assess for burning or redness during infusion.
C. Infuse at a rate of no more than 10 mEq per hour.
D. Administer only through a central venous catheter.
E. Administer by IV push only during cardiac arrest.
✓ A, B, C
✓ RATIONALE:
✓ Interventions to safely administer KCl to a client with hypokalemia
include: using a pharmacy prepared potassium infusion, checking the
client for any burning or redness during infusion, and infusing the IV
2
at not more than 10 mEq per hour. The Joint Commission's National
Page
Client Safety Goals mandates that concentrated potassium be diluted
, and added to IV solutions only in the pharmacy by a registered
pharmacist and that vials of concentrated potassium not be available
in client care areas. IV potassium solutions irritate veins and cause
phlebitis. Assess the IV site hourly, and ask the client whether he or
she feels burning or pain at the site. The presence of pain or burning
at the insertion site may require a new intravenous to be started. A
dose of KCl 5-10 mEq/hour, no more than 20 mEq/hr is
recommended.Potassium may be administered by peripheral or
central vein. There is no circumstance where potassium is given by
IV push.
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.
✓ 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
3
potassium-depleting drugs. Consuming citrus fruit, green leafy
Page
vegetables, cantaloupe, tomato, and other food with potassium is
CRITICAL CARE FLUIDS AND ELECTROLYTES EXAM
IV Therapy, Dehydration, Overload and Emergency
Management
FINAL SPRING EXAM|| QUESTIONS AND ANSWERS||
GRADE A+
A client with diarrhea for 3 days and inability to eat or drink well is brought to the
emergency department (ED) by her family. She states she has been taking her diuretics
for congestive heart failure (CHF). What nursing actions are indicated at this time?
SELECT ALL THAT APPLY.
A. Place the client on bed rest.
B. Evaluate the electrolyte levels.
C. Administer the ordered diuretic.
D. Assess for orthostatic hypotension
E. Initiate cardiac monitoring.
✓ A, B, D, E
✓ RATIONALE:
✓ Nursing actions indicated at this time include: placing the client on
bedrest and assisting the client out of bed, evaluating electrolyte
levels, assessing for orthostatic hypotension, and applying a cardiac
1
Page
monitor. Safety is required to prevent falls due to weakness from a
, likely fluid volume deficit and electrolyte imbalance. The nurse should
review the laboratory and diagnostic results to detect likely loss of
sodium, potassium, and magnesium secondary to diarrhea and
diuretic us. Fluid volume deficit is likely with diarrhea and diuretic use
and leads to fluid and electrolyte imbalances, especially hypokalemia.
Assessing for orthostatic changes will confirm presence of volume
deficit. Monitoring for inverted T wave or presence of U wave on the
ECG as well as dysrhythmias is indicated when hypokalemia is
anticipated.Diuretics increase loss of fluids and electrolytes. The
nurse would question this order in the presence of assessment data
indicating fluid loss from the diuretics and diarrhea.
A client with hypokalemia has a prescription for parenteral potassium chloride (KCl).
Which of these interventions does the nurse use to safely administer KCl?
SELECT ALL THAT APPLY.
A. Use a potassium infusion prepared by a registered pharmacist.
B. Assess for burning or redness during infusion.
C. Infuse at a rate of no more than 10 mEq per hour.
D. Administer only through a central venous catheter.
E. Administer by IV push only during cardiac arrest.
✓ A, B, C
✓ RATIONALE:
✓ Interventions to safely administer KCl to a client with hypokalemia
include: using a pharmacy prepared potassium infusion, checking the
client for any burning or redness during infusion, and infusing the IV
2
at not more than 10 mEq per hour. The Joint Commission's National
Page
Client Safety Goals mandates that concentrated potassium be diluted
, and added to IV solutions only in the pharmacy by a registered
pharmacist and that vials of concentrated potassium not be available
in client care areas. IV potassium solutions irritate veins and cause
phlebitis. Assess the IV site hourly, and ask the client whether he or
she feels burning or pain at the site. The presence of pain or burning
at the insertion site may require a new intravenous to be started. A
dose of KCl 5-10 mEq/hour, no more than 20 mEq/hr is
recommended.Potassium may be administered by peripheral or
central vein. There is no circumstance where potassium is given by
IV push.
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.
✓ 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
3
potassium-depleting drugs. Consuming citrus fruit, green leafy
Page
vegetables, cantaloupe, tomato, and other food with potassium is
