ELITE COMPREHENSIVE
MED-SURG FLUID AND ELECTROLYTE ASSESSMENT
Fluid Balance, Electrolyte Disorders & Acid-Base
Regulation|| FINAL SPRING EXAM|| QUESTIONS AND
ANSWERS|| GRADE A+
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
✓ 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.
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
1
Page
B. Requires Nasogastric suction
, C. Has a history of Addison's disease
D. Is taking a potassium-retaining diuretic
✓ 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.
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
✓ 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.
During an assessment of a newly admitted client, the nurse notes that the client's heart
2
rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands
Page
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
✓ 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.
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
3
✓ Answer: D
Page
✓ 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.
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
✓ 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 98.8° 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.
*Which client is least likely to be at risk for the development of third spacing?
A. The client with cirrhosis
4
B. The client with liver failure
Page
C. The client with diabetes mellitus
MED-SURG FLUID AND ELECTROLYTE ASSESSMENT
Fluid Balance, Electrolyte Disorders & Acid-Base
Regulation|| FINAL SPRING EXAM|| QUESTIONS AND
ANSWERS|| GRADE A+
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
✓ 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.
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
1
Page
B. Requires Nasogastric suction
, C. Has a history of Addison's disease
D. Is taking a potassium-retaining diuretic
✓ 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.
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
✓ 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.
During an assessment of a newly admitted client, the nurse notes that the client's heart
2
rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands
Page
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
✓ 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.
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
3
✓ Answer: D
Page
✓ 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.
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
✓ 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 98.8° 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.
*Which client is least likely to be at risk for the development of third spacing?
A. The client with cirrhosis
4
B. The client with liver failure
Page
C. The client with diabetes mellitus
