SAUNDERS FLUID & ELECTROLYTE
PRACTICE QUESTIONS AND ANSWERS 2022
The nurse is caring for a client with congestive heart failure. On assessment, the
nurse notes that the client is dyspneic and that crackles are audib
...
SAUNDERS FLUID & ELECTROLYTE
PRACTICE QUESTIONS AND ANSWERS 2022
The nurse is caring for a client with congestive heart failure. On assessment, the
nurse notes that the client is dyspneic and that crackles are audible on auscultation.
The nurse suspects excess fluid volume. What additional signs would the nurse
expect to note in this client if excess fluid volume is present?
1) Weight loss
2) Flat neck and hand veins
3) An increase in blood pressure
4) a decreased central venous pressure (CVP) - Answer: 3
Rational: 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 colume 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. Options 1, 2, and 4 identify signs noted in
fluid volume deficit.
A nurse is preparing to care for a client with potassium deficit. The nurse reviews the
client's record and determines that the client was a risk for developing the potassium
deficit because the client:
1) Sustained tissue damage
2) Requires nasogastric suctioning
3) Has a history of Addison's disease
4) Is taking a potassium-sparing diuretic - Answer: 2
Rational: The normal serum potassium level is 3.5 mEq/L to 5 mEq/L. A potassium
deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost
through gastrointestinal section, placing the client at risk for hypokalemia. The client
with tissue damage or Addison's disease and the client taking a potassium-sparing
diuretic are at risk for hyperkalemia.
A nurse reviews a client's electrolyte laboratory report and notes that the potassium
level is 3.2 mEq/L. Which of the following would the nurse note on the
electrocardiogram as a result of the laboratory value?
1) U waves
2) Absent P waves
3) Elevated T waves
4) Elevated ST segment - Answer: 1
Rational: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia.
Potassium deficit is a common electrolyte imbalance and is potentially lifethreatening. Electrocardiographic changes include inverted T waves, ST segment
depression, and prominent U waves. Absent P waves are not a characteristic of
hypokalemia but may be noting in a client with atrial fibrillation (A-fib).
A nursing students needs to administer potassium chloride intravenously as
prescribed to a client with hypokalemia. The nursing instructor determines that the
student is unprepared for this procedure if the student states that which of the
following is part of the plan for preparation and administration of the potassium? CONTINUES...
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