FLUID AND ELECTROLYTE NCLEX TEST WITH VERIFIED ANSWER
100% CORRECT
1. The nurse is administering a blood trans- Rationale: Blood loss causes a
fusion to a client who is hemorrhaging. deficit in the intravascular fluid
In which fluid compartment should the compartment, which is a sub-
nurse identify that the client is experi- compartment of extracellular flu-
encing a deficit? id (ECF). Transcellular and inter
stitial fluids, along with lymph
make up the other compart-
ments of ECF. Intracellular fluid
is the other major fluid compart-
ment in the body.
2. The nurse reviews the care needs for a Rationale: Fluid volume deficit,
group of clients. Which condition should or dehydration, can occur when
the nurse realize occurs from a fluid vol- excessive amounts of fluids are
ume deficit? lost through diarrhea or vomiting.
Kidney failure causes water re-
tention, leading to fluid volume
excess, not deficit. Water intoxi-
cation results from excessive flu-
id intake and leads to fluid vol-
ume excess. Fluid volume ex-
cess, not deficit, can result in hy
pertension.
3. The nurse is reviewing the fluid needs for Rationale: The intracellular flu-
a group of clients. Which characteristic id compartment makes up about
of the intracellular fluid compartment of two thirds of total body fluid
the body should the nurse identify? in adults and is found within
cells. It is a medium for meta-
bolic processes. Extracellular flu-
id makes up the other one third
of total body fluid and is divid-
ed into intravascular, interstitial,
and transcellular fluids. Cere-
brospinal and peritoneal fluids
are examples of transcellular flu-
ids.
4.
,FLUID AND ELECTROLYTE NCLEX TEST WITH VERIFIED ANSWER
100% CORRECT
The nurse is preparing material on fluid Rationale: Body fluids found out-
compartments in the body. Which fluids side of the cell include intravas-
should the nurse identify as the compo- cular, interstitial, and transcellu-
nents of extracellular fluid? lar fluids. Conversely, intracellu-
lar fluids are found inside the cell.
5. The nurse prepares intravenous fluid for Rationale: Osmosis is the move-
a client. Which mechanism should the ment of water across cell mem-
nurse recall that represents the move- branes, from the less-concen-
ment of fluid across cell membranes trated solution to the more-con-
from an area of less concentration to an centrated solution. Filtration is
area of higher concentration? the process by which fluid and
solutes move together across a
membrane from one compart-
ment to another. Active trans-
port is a process by which sub-
stances move across the cell
membrane and must combine
with a carrier for transportation,
requiring metabolic energy. With
diffusion, the molecules move
from a solution of higher concen-
tration to a solution of lower con-
centration.
6. The nurse is caring for a hospitalized Rationale: With increased respi-
client who is experiencing anxiety-re- rations, the client will experience
lated hyperventilation. When calculating a greater-than-normal insensible
the client's intake and output, where loss of fluid through the lungs.
would the nurse anticipate the need for Hyperventilation will not affect
an adjustment in fluid loss? the amount of fluid lost through
the urine, sweat, or feces.
7. The nurse is completing a physical as- Rationale: Physical assessment
sessment with a client. On which part of for fluid and electrolyte status fo-
the body should the nurse focus when cuses on the skin, oral cavity and
determining fluid and electrolyte statusm? ucous membranes, eyes, car-
(Select all that apply.) diovascular and respiratory sys-
tems, and neurologic and mus-
, FLUID AND ELECTROLYTE NCLEX TEST WITH VERIFIED ANSWER
100% CORRECT
cular status. The ears and en-
docrine system are not a focus
of fluid and electrolyte status as-
sessment.
8. The nurse is determining a client's fluidRationale: Daily weight is the
balance. Which method should the nurse best indicator of fluid volume ex-
use to identify this client's fluid volumecess or deficit. Skin turgor, blood
excess or deficit? pressure, and intake and output
are assessments that would be
included in the care of a client
with fluid imbalances, but daily
weight is the best indicator of
changes in fluid status.
9. The nurse is performing an assessment Rationale: Pitting edema, weigh
on a client with fluid volume excess. gain, and crackles in the lungs
Which finding should the nurse identify upon auscultation are indicative
that supports fluid volume excess? (Seo- f fluid volume excess. Tenting of
lect all that apply.) skin and thirst are found in fluid
volume deficit.
10. The nurse is assessing a client with fluid Rationale: Increased hematocrit
volume deficit. Which finding should the is a finding consistent with flu-
nurse identify that supports fluid volume id volume deficit. Edema and
deficit? weight gain are consistent with
fluid volume overload. Wheezes
upon auscultation of the lungs is
not related to fluid imbalances.
11. The school nurse notes that a Rationale: To prevent heat-relat-
school-age child is experiencing mild ed illness, it would be best to
heat exhaustion after playing outside move recess from the hottest
during recess. Which recommendation part of the day to a cooler part
should the nurse make to help prevent of the day. Children should be
future occurrences of heat-related ill- encouraged to take frequent wa-
ness? ter breaks and drink before they
begin to feel thirsty, not just when
they feel thirsty or only before
recess. Children should also be
100% CORRECT
1. The nurse is administering a blood trans- Rationale: Blood loss causes a
fusion to a client who is hemorrhaging. deficit in the intravascular fluid
In which fluid compartment should the compartment, which is a sub-
nurse identify that the client is experi- compartment of extracellular flu-
encing a deficit? id (ECF). Transcellular and inter
stitial fluids, along with lymph
make up the other compart-
ments of ECF. Intracellular fluid
is the other major fluid compart-
ment in the body.
2. The nurse reviews the care needs for a Rationale: Fluid volume deficit,
group of clients. Which condition should or dehydration, can occur when
the nurse realize occurs from a fluid vol- excessive amounts of fluids are
ume deficit? lost through diarrhea or vomiting.
Kidney failure causes water re-
tention, leading to fluid volume
excess, not deficit. Water intoxi-
cation results from excessive flu-
id intake and leads to fluid vol-
ume excess. Fluid volume ex-
cess, not deficit, can result in hy
pertension.
3. The nurse is reviewing the fluid needs for Rationale: The intracellular flu-
a group of clients. Which characteristic id compartment makes up about
of the intracellular fluid compartment of two thirds of total body fluid
the body should the nurse identify? in adults and is found within
cells. It is a medium for meta-
bolic processes. Extracellular flu-
id makes up the other one third
of total body fluid and is divid-
ed into intravascular, interstitial,
and transcellular fluids. Cere-
brospinal and peritoneal fluids
are examples of transcellular flu-
ids.
4.
,FLUID AND ELECTROLYTE NCLEX TEST WITH VERIFIED ANSWER
100% CORRECT
The nurse is preparing material on fluid Rationale: Body fluids found out-
compartments in the body. Which fluids side of the cell include intravas-
should the nurse identify as the compo- cular, interstitial, and transcellu-
nents of extracellular fluid? lar fluids. Conversely, intracellu-
lar fluids are found inside the cell.
5. The nurse prepares intravenous fluid for Rationale: Osmosis is the move-
a client. Which mechanism should the ment of water across cell mem-
nurse recall that represents the move- branes, from the less-concen-
ment of fluid across cell membranes trated solution to the more-con-
from an area of less concentration to an centrated solution. Filtration is
area of higher concentration? the process by which fluid and
solutes move together across a
membrane from one compart-
ment to another. Active trans-
port is a process by which sub-
stances move across the cell
membrane and must combine
with a carrier for transportation,
requiring metabolic energy. With
diffusion, the molecules move
from a solution of higher concen-
tration to a solution of lower con-
centration.
6. The nurse is caring for a hospitalized Rationale: With increased respi-
client who is experiencing anxiety-re- rations, the client will experience
lated hyperventilation. When calculating a greater-than-normal insensible
the client's intake and output, where loss of fluid through the lungs.
would the nurse anticipate the need for Hyperventilation will not affect
an adjustment in fluid loss? the amount of fluid lost through
the urine, sweat, or feces.
7. The nurse is completing a physical as- Rationale: Physical assessment
sessment with a client. On which part of for fluid and electrolyte status fo-
the body should the nurse focus when cuses on the skin, oral cavity and
determining fluid and electrolyte statusm? ucous membranes, eyes, car-
(Select all that apply.) diovascular and respiratory sys-
tems, and neurologic and mus-
, FLUID AND ELECTROLYTE NCLEX TEST WITH VERIFIED ANSWER
100% CORRECT
cular status. The ears and en-
docrine system are not a focus
of fluid and electrolyte status as-
sessment.
8. The nurse is determining a client's fluidRationale: Daily weight is the
balance. Which method should the nurse best indicator of fluid volume ex-
use to identify this client's fluid volumecess or deficit. Skin turgor, blood
excess or deficit? pressure, and intake and output
are assessments that would be
included in the care of a client
with fluid imbalances, but daily
weight is the best indicator of
changes in fluid status.
9. The nurse is performing an assessment Rationale: Pitting edema, weigh
on a client with fluid volume excess. gain, and crackles in the lungs
Which finding should the nurse identify upon auscultation are indicative
that supports fluid volume excess? (Seo- f fluid volume excess. Tenting of
lect all that apply.) skin and thirst are found in fluid
volume deficit.
10. The nurse is assessing a client with fluid Rationale: Increased hematocrit
volume deficit. Which finding should the is a finding consistent with flu-
nurse identify that supports fluid volume id volume deficit. Edema and
deficit? weight gain are consistent with
fluid volume overload. Wheezes
upon auscultation of the lungs is
not related to fluid imbalances.
11. The school nurse notes that a Rationale: To prevent heat-relat-
school-age child is experiencing mild ed illness, it would be best to
heat exhaustion after playing outside move recess from the hottest
during recess. Which recommendation part of the day to a cooler part
should the nurse make to help prevent of the day. Children should be
future occurrences of heat-related ill- encouraged to take frequent wa-
ness? ter breaks and drink before they
begin to feel thirsty, not just when
they feel thirsty or only before
recess. Children should also be
