Saunders Fluid and Electrolytes
Important Note: Lab Values in Saunders and different facilities may differ from
the slides. For testing purposes, please use the normal lab values in the slides.
1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is
dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse
expect to note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP)
Correct answer: 3
Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid
intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid
volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure,
bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of
consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output
{is noted in fluid volume excess}, and decreased CVP are noted in fluid volume deficit. Weakness can be
present in either fluid volume excess or deficit.
NOTE: In fluid volume excess, the intake usually exceeds the output and thus urine output decreases.
What makes option 2 incorrect is the flat neck veins. In fluid volume excess, neck veins will be
distended.
Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Comparable or Alike Options, Subject
Priority Concepts: Fluid and Electrolyte Balance, Perfusion
2. 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 is at risk for developing the potassium deficit because of which
situation?
1. Sustained tissue damage
2. Requires nasogastric suction
3. Has a history of Addison's disease
4. Uric acid level of 9.4 mg/dL (559 mmol/L)
,Correct answer: 2
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/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 with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3
mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a
cause of hyperkalemia.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
4. The nurse provides instructions to a client with a low potassium level about the foods that are high in
potassium and tells the client to consume which foods? Select all that apply.
1. Peas
2. Raisins
3. Potatoes
4. Cantaloupe
5. Cauliflower
6. Strawberries
Correct answer: 2, 3, 4, 6
Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of
potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork,
beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Subject
Priority Concepts: Client Education, Nutrition
5. The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L
(150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP
prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse
instruct the client to consume? Select all that apply.
, 1. Peas
2. Nuts
3. Cheese
4. Cauliflower
5. Processed oat cereals
Correct answer: 1, 2, 4
Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium
level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would
instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of
phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of
magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Subject
Priority Concepts: Client Education, Nutrition
6. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical
manifestation would the nurse expect to note in the client?
1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau's sign
4. Hypoactive deep tendon reflexes
Correct answer: 1
Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium
level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include
paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or
Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle
cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased
gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Comparable or Alike Options
Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
Important Note: Lab Values in Saunders and different facilities may differ from
the slides. For testing purposes, please use the normal lab values in the slides.
1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is
dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse
expect to note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output
3. An increase in blood pressure and increased respirations
4. Weakness and decreased central venous pressure (CVP)
Correct answer: 3
Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid
intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid
volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure,
bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of
consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output
{is noted in fluid volume excess}, and decreased CVP are noted in fluid volume deficit. Weakness can be
present in either fluid volume excess or deficit.
NOTE: In fluid volume excess, the intake usually exceeds the output and thus urine output decreases.
What makes option 2 incorrect is the flat neck veins. In fluid volume excess, neck veins will be
distended.
Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Comparable or Alike Options, Subject
Priority Concepts: Fluid and Electrolyte Balance, Perfusion
2. 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 is at risk for developing the potassium deficit because of which
situation?
1. Sustained tissue damage
2. Requires nasogastric suction
3. Has a history of Addison's disease
4. Uric acid level of 9.4 mg/dL (559 mmol/L)
,Correct answer: 2
Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/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 with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3
mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a
cause of hyperkalemia.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
4. The nurse provides instructions to a client with a low potassium level about the foods that are high in
potassium and tells the client to consume which foods? Select all that apply.
1. Peas
2. Raisins
3. Potatoes
4. Cantaloupe
5. Cauliflower
6. Strawberries
Correct answer: 2, 3, 4, 6
Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of
potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork,
beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Subject
Priority Concepts: Client Education, Nutrition
5. The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L
(150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP
prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse
instruct the client to consume? Select all that apply.
, 1. Peas
2. Nuts
3. Cheese
4. Cauliflower
5. Processed oat cereals
Correct answer: 1, 2, 4
Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium
level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would
instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of
phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of
magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Subject
Priority Concepts: Client Education, Nutrition
6. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical
manifestation would the nurse expect to note in the client?
1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau's sign
4. Hypoactive deep tendon reflexes
Correct answer: 1
Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium
level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include
paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or
Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle
cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased
gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Fundamentals of Care: Fluid and Electrolytes
Strategy(ies): Comparable or Alike Options
Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
