NCLEX Electrolytes
NCLEX-Electrolytes
NCLEX
NCLEX
NCLEX
100
Nurse receives report from a paramedic on an unresponsive client. The report states the client was found one the floor next to an empty bottle of aspirin. The Vitals are BP 99/68, P 121, RR 42 and deep. Which ABG findings should the nurse expect? A. pH-7.68, PO2-96, CO2-38, HCO3-28 B. pH-7.48, PO2-100, PCO2-28, HCO3-23 C. pH-6.98, PO2-100, CO2-30, HCO3-18 D. pH-7.58, PO2-96, CO2-38, HCO3-29
What is C. pH-6.98, PO2-100, CO2-30, HCO3-18
100
A client is exhibiting sudden onset of crackles in the lungs, moist respirations, and rapid respiratory rate. Which intervention should be performed first? A. Weight the client B. Assess capillary refill C. Measure edema D. Reduce IV rate
What is D. Reduce IV rate Rationale: Weighing the client and measuring edema are important interventions in clients with fluid volume excess. However, the priority intervention is to reduce the cause of the excess, in this case, the IV fluid. Capillary refill is an important assessment but is not specific for assessing fluid balance.
100
ABGs of a client admitted to the ED shows pH 7.24, PCO2 65, and HCO3 24. The client is diagnosed with bacterial pneumonia and is started on antibiotics and oxygen. What is a priority nursing intervention? A. Encourage coughing and deep breathing B. Monitor vital signs frequently C. Monitor cardiac rhythm D. Encourage leg exercises
What is A. Encourage coughing and deep breathing Rationale: The ABGs reveal respiratory acidosis. A primary intervention is to increase ventilation through deep breathing and removal of secretions. Although vital sign and cardiac assessment are important, increasing ventilation will help resolve the problem. Leg exercises may be encouraged to prevent deep vein thrombosis, but are not related to the ABGs presented in this scenario.
100
A client has symptoms related to erosion of the esophagus. Which is the correct label for painful swallowing? A. Pyrosis B. Dysphagia C. Odynophagia D. Esophagitis
What is C. Odynophagia Rationale: Odynophagia is the correct label for symptoms related to erosion of the esophagus.
100
Crohn's disease impairs the digestive process. The nurse's assessment would include evidence of: A. Nausea and vomiting B. Weight loss and anemia C. Absence of bowel sounds D. Constipation and abdominal distention
What is B. Weight loss and anemia Rationale: Assessment of Crohn’s disease would include evidence of weight loss and anemia.
200
Parent report their 6 month old has had diarrhea and vomiting for 24 ours. Which assessment fiddling do your expect to find that suggests fluid volume deficit? A. Swelling of extremities B. Increased number of diaper changes C. Depressed fontanelles D. Weight gain
What is C. Depressed fontanelles. Rationale: Swelling and weight gain are signs of fluid volume excess. Although the child may need increased diaper changes because of diarrhea, those are not a sign of fluid volume deficit. Depressed fontanelles occur in young children with fluid volume deficit.
200
The assessment of a client with hypokalemia should focus on: A. Blood pressure B. Edema C. Chvostek's sign D. Heart rhythm
What is D. Heart rhythm Rationale: The major risk associated with a low potassium level is cardiac dysrhythmia. Chvostek’s sign is associated with hypocalcemia. Although blood pressure may be affected by cardiac dysrhythmia, it is not specific to potassium balance. Edema is associated with fluid balance.
200
The client most at risk for metabolic alkalosis is: A. 30 year old post surgical client undergoing nasogastric suction B. 70 year old client in nursing home unable to access water freely C. 2 year old infant receiving isotonic sodium chloride IV solution D. 54 year old client who has just experienced a stroke
What is A. 30 year old post surgical client undergoing NG suction Rationale: Removal of gastric acids may result in metabolic alkalosis. The client unable to access water is at risk for fluid volume deficit and hypernatremia. The infant is at risk for fluid volume excess. The client experiencing a stroke is not at risk for a specific fluid, electrolyte, or acid-base imbalance.
200
A client is having GI pain, located in a specific body region. This is: A. Visceral pain B. Somatic pain C. Referred pain D. Abdominal pain
What is B. Somatic pain Rationale: Somatic pain is the correct label for GI pain that is specific to a region of the body.
200
IBS symptoms can exacerbate following which events?: A. Anticholeric medications B. Weather changes C. Sexual activity D. Dietary intolerances
What is D. Dietary intolerances Rationale: IBS symptoms can exacerbate following dietary intolerances.
300
In prioritizing client care, you recognize that the client most at risk for fluid volume deficit is: A. 30 year old man with fractured tibia B. 82 year old woman with fractured hip C. 62 year old man with myocardial infarction D. 35 year old woman who just delivered a baby
What is B. 82 year old woman with fractured hip. Rationale: Although all of these clients might experience fluid volume deficit, the most at risk are clients at the extreme of age, either young or old; in this case the 82-year-old client.
300
You are caring for a client with hyperkalemia. You prepare for administration of which medication? A. Kayexalate B. K-Lor C. Kaopectate D. Keflex
What is A. Kayexalate Rationale: Kayexalate is indicated for the removal of excess potassium. K-Lor is a potassium supplement indicated for clients with hypokalemia. Kaopectate is an antidiarrheal medicine, and Keflex is an antibiotic.
300
Which set of ABGs indicate compensated respiratory alkalosis? A. pH-7.43, PCO2-32, HCO3-18 B. pH-7.49, PCO2-32, HCO3-20 C. pH-7.39, PCO2-48, HCO3-28 D. pH-7.43, PCO2-38, HCO3-23
What is A. pH-7.43, PCO2-32, HCO3-18 Rationale: The PCO2 is low, indicating alkalosis. To compensate, the body has excreted excess bicarbonate, and the HCO3 is low. This compensation has returned the pH within normal range.
300
A client has pain in the esophagus from esophagitis. This pain can be confused with: A. Dental disorders of the teeth B. Cardiac pain C. Appendicitis D. Acute bronchitis
What is B. Cardiac pain Rationale: Pain in the esophagus from esophagitis can be confused as cardiac pain.
300
Modifications int he daily diet to alleviate IBS symptoms include: A. high soluble fiber diet B. diet low in fat C. increase in water intake D. high protein diet
What is A. high soluble fiber diet Rationale: Modifications in the daily diet to alleviate IBS symptoms include a high soluble fiber diet.
400
Priority assessment for client with fluid volume excess is: A. Mental status B. Weight C. Postural Vital signs D. Urine output
What is B. Weight Rationale: Mental status is rarely affected in a fluid excess without a change in osmolality. Postural vital signs are most important in clients with fluid volume deficit. Urine output may be increased or decreased, depending on the cause of the fluid excess. Weight is an important indicator of fluid balance.
400
The most important assement in a client with hypocalcemia is: A. Heart rhythm B. Urine output C. Trousseau's sign D. Weight
What is C. Trousseau's sign. Rationale: While hypocalcemia may affect cardiac rhythm, Trousseau’s sign is most specific to calcium balance. Urine output and weight are important assessment parameters for fluid balance.
400
_____ is the ability to cause fluid movement across membranes. A. Osmosis B. Hypertonic C. Tonicity D. Osmolality
What is C. Tonicity Rationale: Tonicity is the ability to cause fluid movement across membranes. Osmosis is the movement of fluid through a semipermeable membrane. Hypertonicity refers to solutions that cause fluid to move out of the cell resulting in shrinking of the cells.
400
A client has been experiencing heartburn after meals and some regurgitation of fluids that taste foul, and she is often not able to lie down comfortably just after eating. This is most likely: A. GERD B. Stomach cancer C. Achalasia D. Peptic ulceration
What is A. GERD Rationale: GERD is characterized by heartburn after meals, some regurgitation of fluids that are foul tasting when the client is full, and the client often is not able to lie down comfortably just after eating.
400
IBS is best described as: A. Syndrome involving multisystems and many complaints B. Cluster of vague abdominal complaint with no remission times C. Functional bowel disorder with no signs of pathology present D. The presence of diarrhea as the most prominent symptom
What is C. A functional bowel disorder with no signs of pathology present Rationale: IBS is best described as a functional bowel disorder with no signs of pathology present.
500
A client present with a serum sodium level of 115 mEq/L. A priority nursing intervention is: A. Seizure precautions B. Vital signs every 2 hours C. Frequent oral care D. Cardiac rhythm monitoring
What is A. Seizure precautions. Rationale: Clients with hyponatremia are at high risk for seizures. Vital sign assessment is important, but client safety takes priority. Frequent oral care would be important in a client with hypernatremia or fluid volume deficit. Cardiac monitoring is important in hyperkalemia or hypokalemia.
500
A client who has experienced cardiac arrest is most at risk for: A. Metabolic acidosis B. Respiratory alkalosis C. Hyponatremia D. Fluid volume excess
What is A. Metabolic acidosis Rationale: Cardiac arrest is associated with tissue hypoxia and development of lactic acidosis. This causes a metabolic acidosis.
500
Too much of which electrolyte can lead to respiratory depression and arrest? A. Calcium B. Magnesium C. Potassium D. Chloride
What is B. Magnesium Rationale: Magnesium is important in the transmission of neuromuscular impulses. Too much magnesium may cause respiratory muscle depression leading to respiratory depression and arrest. Calcium is found mostly in teeth and bones and is involved in blood coagulation. It is also involved in muscle contraction and nerve impulse transmission. Potassium is necessary for the transmission of nerve impulses, cardiac rhythms, and muscle contraction. Chloride is found in the blood and in the stomach combined with other substances.
500
A pregnant client is experiencing pyrosis and regurgitation after eating meals. This is most likely: A. Esophagitis B. Gastritis C. Hiatal Hernia D. Aphagia
What is C. Hiatal Hernia Rationale: A hiatal hernia is the most likely condition when the client is pregnant and experiencing pyrosis and regurgitation after eating her meals.
500
The nurse's teaching strategies for clients who have IBS would focus on: A. Lifestyle changes B. Bowel hygiene C. Dietary modifications D. Response to medications
What is C. Dietary modifications Rationale: Teaching strategies for clients who have IBS would focus on dietary modifications.
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