Electrolytes
A client is admitted with a serum potassium level of 6.5 mEq/L. Which of the following orders should the nurse question?
Answer: B. Administer potassium chloride IV push. (This would worsen the hyperkalemia.)
A patient with chronic respiratory disease has the following ABG: pH 7.36, PaCO2 52 mmHg, HCO3 28 mEq/L. What does this indicate?
B. Compensated respiratory acidosis (The pH is normal but on the acidic side, PaCO2 is high, and HCO3 is elevated, indicating compensation.)
Which clinical manifestation would the nurse expect to see in a client with hypervolemia?
B. Crackles in the lungs and edema. (These are classic signs of fluid overload.)
A nurse is assessing an infant’s growth. Which finding indicates normal growth?
A. Birth weight triples by 6 months
B. Birth weight doubles by 5 months
C. Length increases by 10% in the first year
D. Head circumference decreases after 6 months
Correct Answer: ✅ B
Rationale:
Infants typically double birth weight by 4–6 months and triple it by 12 months. Head circumference increases in infancy, not decreases.
Which of the following are classified as isotonic IV fluids? SATA
A. Normal Saline (0.9% NaCl)
B. Lactated Ringer’s (LR) are both isotonic solutions because they have a similar osmolarity to the blood, and they don't cause fluid shifts between compartments.
C. D5W (5% Dextrose in Water) is initially isotonic but becomes hypotonic once the dextrose is metabolized, which is why it is often debated for classification. However, it's commonly used as an isotonic fluid for initial administration before metabolism.
The nurse is caring for a client with hypermagnesemia. Which of the following symptoms would the nurse expect?
A client’s ABG results are: pH 7.35, PaCO2 48 mmHg, HCO3 30 mEq/L. What does this indicate?
Answer:
A client with a sodium level of 156 mEq/L is confused and thirsty. What is the priority nursing action?
The nurse is teaching parents of a toddler. Which behavior is expected for this age group?
A. Cooperative play
B. Fear of strangers
C. Autonomy and saying “no”
D. Logical thinking
Correct Answer: ✅ C
Rationale:
Toddlers are focused on autonomy (Erikson) and often test limits by saying “no.”
A patient with hyponatremia is ordered 3% NaCl IV. What is the most important nursing action?
A. Monitor for signs of dehydration
B. Check hourly urine output
C. Infuse rapidly to raise sodium quickly
D. Monitor for fluid overload and neurological changes
Correct Answer: D. Monitor for fluid overload and neurological changes
Rationale:
Hypertonic fluids like 3% NaCl pull water out of cells. They must be given slowly and carefully, often in critical care, and require close monitoring to prevent fluid overload or cerebral demyelination.
A nurse is caring for a client with hypernatremia. Which of the following would the nurse prioritize in the care plan?
Answer: B. Providing oral fluids and monitoring intake and output.
(The primary treatment for hypernatremia is restoring fluid balance.)
A client is admitted with a respiratory rate of 28 breaths per minute due to anxiety. What intervention should the nurse implement first?
Answer:
A client is admitted with a heart rate of 115 bpm, low blood pressure, and dry mucous membranes. What is the priority intervention?
Answer:
A preschooler believes a monster lives under the bed. How should the nurse respond?
A. “That is not real.”
B. “You are too old for that fear.”
C. “Many children feel scared sometimes.”
D. “You should be brave.”
Correct Answer: ✅ C
Rationale:
Preschoolers have active imaginations. The nurse should acknowledge feelings without reinforcing fear.
A client’s IV rate is set to deliver 1,000 mL over 8 hours with tubing that has a drip factor of 15 gtt/mL. What is the drip rate in drops per minute (gtt/min)?
Answer: B. 31 gtt/min. (1,000 ÷ 480 × 15 = 31.25, rounded to 31.)
A client with a sodium level of 118 mEq/L is being treated with hypertonic saline (3%). Which of the following symptoms would indicate rapid correction of hyponatremia?
Answer: D. Neurological symptoms such as seizures.
(Rapid correction of sodium levels can lead to osmotic demyelination syndrome.)
A client with COPD is admitted with ABGs showing pH 7.31, PaCO2 60 mmHg, and HCO3 24 mEq/L. What is the priority intervention?
Answer:
Which finding is the most reliable indicator of a client’s hydration status?
Answer:
Which teaching strategy is most effective when caring for adolescents?
A. Give instructions only to parents
B. Use simple yes/no questions
C. Allow privacy and involve them in decisions
D. Avoid discussion of sensitive topics
Correct Answer: ✅ C
Rationale:
Adolescents value autonomy, respect, and privacy, improving cooperation and learning.
A nurse notices that a patient has a red, swollen, and warm IV insertion site. What is the most likely cause?
Correct Answer: B. Phlebitis
Rationale:
A patient with chronic kidney disease presents with fatigue, nausea, and a potassium level of 6.1 mEq/L. Which orders or findings should the nurse anticipate?
Select all that apply:
A. Continuous cardiac monitoring
B. Prepare the patient for dialysis
C. Administer IV furosemide
D. Avoid salt substitutes
E. Administer sodium bicarbonate
F. Encourage high-potassium foods
G. Wide QRS complex on ECG
H. Give spironolactone
A, B, C, D, E, G
Rationales:
A. Continuous cardiac monitoring — YES
Potassium over 6 requires close ECG monitoring.
B. Prepare the patient for dialysis — YES
CKD patients often need emergent dialysis to remove potassium.
C. IV furosemide — YES
Loop diuretics increase potassium excretion (if kidneys still have some function).
D. Avoid salt substitutes — YES
They often contain potassium chloride, which worsens hyperkalemia.
E. Sodium bicarbonate — YES
Used especially in acidosis; shifts K+ into cells.
F. Encourage high-potassium foods — NO
Foods like bananas, potatoes, oranges would worsen hyperkalemia.
G. Wide QRS complex — YES
Hyperkalemia causes peaked T waves → widened QRS → sine-wave pattern as it worsens.
H. Give spironolactone — NO
This is a potassium-sparing diuretic → makes potassium rise even more.
``A nurse is caring for a client with COPD. Which findings are consistent with respiratory acidosis? (Select all that apply.)
Answers:
An 82-year-old client is admitted with dehydration and reports dizziness and fatigue. Which assessment findings are consistent with fluid volume deficit? (Select all that apply.)
Answer:
(Explanation: Dehydration causes delayed capillary refill, flattened neck veins, hypotension, and dry oral mucosa. Bounding pulses are associated with fluid volume excess.)
Which findings are normal age‑related changes in older adults?
Select all that apply.
A. Slower reaction time
B. Short‑term memory loss affecting daily function
C. Decreased skin elasticity
D. Preserved long‑term memory
E. Sudden confusion
Correct Answers: ✅ A, C, D
Rationale:
Normal aging includes slower reactions, skin changes, and preserved long‑term memory. Sudden confusion and memory loss affecting function are not normal.
Fluid Type | Match to Use Case
0.9% NS | A. Cellular dehydration (e.g., DKA)
0.45% NaCl | B. Hypovolemia or blood loss
D5W (initially) | C. Hypernatremia
3% NaCl | D. Symptomatic hyponatremia
Answers:
0.9% NS → B
0.45% NaCl → A
D5W → C
3% NaCl → D
0.9% NS → B. Hypovolemia or blood loss
Rationale:
0.9% Normal Saline is isotonic, meaning it stays in the intravascular and interstitial space and expands extracellular volume without shifting fluid into or out of cells. It's commonly used for hypovolemia, dehydration, blood loss, and during blood transfusions because it won’t cause hemolysis of red blood cells.
0.45% NaCl → A. Cellular dehydration (e.g., DKA)
Rationale:
0.45% Normal Saline is a hypotonic solution. It shifts water into the cells, making it ideal for treating cellular dehydration, such as in diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic states (HHS), where intracellular fluid is depleted.
D5W (initially isotonic, then hypotonic) → C. Hypernatremia
Rationale:
D5W (5% dextrose in water) is isotonic in the bag but becomes hypotonic once the dextrose is metabolized. It leaves behind free water that moves into cells, helping dilute high sodium levels. It's useful in treating hypernatremia, but caution is needed in patients at risk of increased intracranial pressure.
3% NaCl → D. Symptomatic hyponatremia
Rationale:
3% Normal Saline is hypertonic and pulls water out of cells into the extracellular space. It is used cautiously in severe or symptomatic hyponatremia (e.g., with seizures or confusion) to raise serum sodium. Frequent monitoring of sodium levels and neurologic status is critical to avoid complications like osmotic demyelination syndrome.