Question 1

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Accepted Answer

Answer reason: Metabolic alkalosis. Gastric suction via an NG tube removes hydrochloric acid (H+) and chloride from the stomach. Loss of H+ increases serum bicarbonate relative to acids, producing a metabolic alkalosis (often accompanied by hypochloremia and possible hypokalemia). Therefore, the nurse should monitor for metabolic alkalosis as the most likely acid-base disturbance.
Category reason: This question tests nursing monitoring for an expected acid-base/electrolyte complication from a therapeutic intervention (nasogastric suction), which fits NCLEX patient-care judgment under Fluid and Electrolyte Imbalances.

Question 2

The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 ml daily." Which client is at risk for this loss?

Accepted Answer

Answer reason: Insensible fluid loss occurs through respiration and skin. Tachypnea significantly increases fluid loss through the lungs.
Category reason: The question tests understanding of fluid balance and causes of fluid loss.

Question 3

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?

Accepted Answer

Answer reason: A potassium level of 3.2 mEq/L. Respiratory alkalosis (high pH with low PaCO2) commonly causes potassium to shift into cells in exchange for hydrogen ions, leading to a decreased serum potassium level (hypokalemia). A potassium of 3.2 mEq/L reflects this expected electrolyte change. The other listed values are within typical reference ranges and are not characteristic compensatory/associated findings of acute respiratory alkalosis.
Category reason: This item tests recognition of electrolyte changes (notably hypokalemia) associated with an acid–base disturbance and what lab value a nurse should anticipate, which fits Fluid and Electrolyte Imbalances.

Question 4

When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate taking?

Accepted Answer

Answer reason: Restrict patients oral free water intake. Hyponatremia commonly results from excess free water relative to sodium, so restricting free water helps prevent further dilution and supports correction of serum sodium. Electrolyte-containing drinks are not avoided; they may help provide sodium compared with plain water. D5 in 0.45% saline is hypotonic overall and can worsen hyponatremia. Vasopressin/ADH promotes water retention and would generally aggravate hyponatremia unless treating a specific condition like central diabetes insipidus (which presents with hypernatremia).
Category reason: This item tests nursing management of an electrolyte disturbance (hyponatremia) and appropriate fluid-related interventions, which aligns with Fluid and Electrolyte Imbalances.

Question 5

A client with renal failure has a potassium level of 6.4 mEq/L. What is the priority nursing action?

Accepted Answer

Answer reason: Administer IV insulin and glucose. A potassium of 6.4 mEq/L is severe hyperkalemia, creating an immediate risk for life-threatening dysrhythmias, especially in renal failure where potassium excretion is impaired. IV regular insulin with glucose rapidly shifts potassium into cells, lowering serum potassium quickly while preventing hypoglycemia. The other options either worsen hyperkalemia (high potassium diet), are not rapid/appropriate for emergent management (oral bicarbonate tablets), or may be unsafe/ineffective as a priority intervention in renal failure (encouraging fluids).
Category reason: This is a priority nursing intervention for an acute electrolyte abnormality (hyperkalemia) with potential for cardiac instability, fitting NCLEX Physiological Adaptation → Fluid and Electrolyte Imbalances.

Question 6

Which of the following is not an appropriate nursing intervention for a patient with hypercalcemia?

Accepted Answer

Answer reason: administering calcium gluconate Calcium gluconate is used to treat hypocalcemia and to stabilize the cardiac membrane in severe hyperkalemia, not to lower an elevated calcium level. In hypercalcemia, appropriate measures include promoting calciuresis (e.g., loop diuretics with adequate hydration), inhibiting bone resorption (e.g., calcitonin), and encouraging ambulation to reduce bone demineralization from immobility. Giving calcium gluconate would risk worsening the hypercalcemia and its complications (e.g., dysrhythmias, neurologic changes, kidney stones).
Category reason: The question asks the nurse to choose an appropriate intervention for an electrolyte disturbance (hypercalcemia), which is a patient-care management decision under Fluid and Electrolyte Imbalances.

Question 7

Managing a sodium level of 120 in a client with diabetic ketoacidosis is correctly accomplished with?

Accepted Answer

Answer reason: Insulin and 0.9% sodium chloride In DKA, hyponatremia is commonly dilutional/pseudohyponatremia due to hyperglycemia-driven water shift from cells into the intravascular space, and the priority is treating DKA with isotonic fluid resuscitation plus insulin. 0.9% normal saline restores circulating volume and improves renal perfusion, while insulin lowers glucose and corrects the transcellular water shift, allowing sodium to normalize as hyperglycemia resolves. Hypertonic 3% saline is reserved for severe symptomatic hyponatremia (e.g., seizures/coma) and risks overly rapid correction; fluid restriction and oral salt tablets are inappropriate in acute DKA dehydration.
Category reason: This is a nursing management question about acute treatment of DKA with associated electrolyte abnormality, requiring selection of appropriate fluids/insulin to correct a fluid and electrolyte imbalance.

Question 8

Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?

Accepted Answer

Answer reason: D. 18-year-old Albert who has renal disease Impaired kidney function reduces potassium excretion, placing the client at high risk for hyperkalemia. Elevated potassium can precipitate dangerous cardiac dysrhythmias, so dietary potassium restriction is a key prevention strategy. In contrast, many diuretics (especially loop/thiazide) increase potassium loss, and ileostomy losses more commonly contribute to fluid, sodium, and bicarbonate deficits rather than potassium retention. Metabolic acidosis can shift potassium out of cells, but without impaired renal excretion, dietary restriction is not the primary universal teaching point.
Category reason: This question asks the nurse to identify which client scenario warrants specific patient teaching to prevent electrolyte-related complications, which is a nursing judgment about managing fluid/electrolyte imbalance risks.

Question 9

Which nursing diagnosis is most appropriate for a patient experiencing frequent episodes of diarrhea?

Accepted Answer

Answer reason: Deficient Fluid Volume Frequent diarrhea causes ongoing gastrointestinal fluid losses, placing the patient at high risk for dehydration and electrolyte imbalance. This diagnosis directly addresses the most immediate physiologic threat and guides interventions such as monitoring intake/output, assessing vital signs and mucous membranes, and replacing fluids and electrolytes as indicated. The other options may be relevant in specific circumstances, but they are not as universally or urgently tied to the primary complication of persistent diarrhea.
Category reason: This is a patient-care judgment question requiring selection of the most appropriate nursing diagnosis based on expected complications of diarrhea, which aligns with NCLEX-style clinical decision-making about fluid/electrolyte risk.

Question 10

A newborn with a glucose level of 22 mg/dL is lethargic and jittery. What is the priority intervention?

Accepted Answer

Answer reason: B. Begin IV 10% dextrose bolus A symptomatic neonate with a glucose of 22 mg/dL has severe hypoglycemia, which can rapidly cause seizures and brain injury if not corrected promptly. Immediate IV dextrose is indicated when the infant is symptomatic and/or unable to reliably tolerate or respond quickly enough to oral feeds. Feeding and warming may be supportive, but they do not correct critical hypoglycemia fast enough to prevent neurologic complications. Delaying care is unsafe given the low value and symptoms.
Category reason: This question requires selecting the safest, highest-priority nursing intervention for an acutely symptomatic newborn, which is a patient-care priority decision aligned with NCLEX Physiological Adaptation and management of metabolic/fluid imbalance.

Question 11

A client with Cushing's syndrome has a serum potassium of 2.8 mEq/L. What is the nurse's priority?

Accepted Answer

Answer reason: B. Notify the physician and monitor cardiac status A potassium level of 2.8 mEq/L is significant hypokalemia, which can precipitate dangerous dysrhythmias and requires immediate assessment and escalation of care. In Cushing’s syndrome, excess cortisol has mineralocorticoid effects that increase potassium loss, making urgent correction and continuous cardiac monitoring appropriate. Dietary potassium is too slow for this severity, and dialysis is not indicated for isolated hypokalemia. Fluid restriction does not address the immediate life-threatening risk of arrhythmia.
Category reason: This item tests the nurse’s priority actions for a clinically significant electrolyte abnormality (hypokalemia) with potential for acute cardiac complications, which aligns with Fluid and Electrolyte Imbalances under Physiological Adaptation.

Question 12

A nurse is teaching a client with SIADH about fluid restriction. Which statement shows understanding?

Accepted Answer

Answer reason: k." SIADH causes excess water retention and dilutional hyponatremia, so treatment commonly includes strict fluid restriction. Accurately tracking all oral intake helps the client adhere to the prescribed fluid limit and reduces risk of worsening hyponatremia and neurologic complications. The other statements promote increased or unrestricted fluid intake or focus on salt restriction, which does not address the core problem of water excess in SIADH.
Category reason: This is a patient-teaching question about managing SIADH through fluid restriction to prevent complications from hyponatremia, which falls under nursing care for fluid and electrolyte imbalances.

Question 13

A nurse receives a patient with DKA. Which intervention is done first?

Accepted Answer

Answer reason: A. Initiate IV normal saline DKA causes profound osmotic diuresis leading to hypovolemia, decreased renal perfusion, and shock risk, so immediate isotonic fluid resuscitation is the priority. Restoring intravascular volume improves tissue perfusion and helps lower glucose by dilution and increased renal clearance. Insulin is started after initial fluids and once potassium status is assessed/managed to avoid precipitating dangerous hypokalemia. Bicarbonate is generally reserved for severe acidosis (e.g., very low pH) due to potential harms and is not the first-line initial step.
Category reason: This is a priority nursing intervention question in an acute emergency (DKA) focusing on immediate stabilization of fluid status and prevention of complications, which aligns with NCLEX Physiological Adaptation—Fluid and Electrolyte Imbalances.

Question 14

A nurse is monitoring a patient on loop diuretics. Which nutrient loss should be carefully monitored and replaced?

Accepted Answer

Answer reason: Loop diuretics (e.g., furosemide) increase urinary excretion of multiple electrolytes, notably potassium and magnesium, creating risk for hypomagnesemia. Low magnesium can precipitate neuromuscular irritability and increases susceptibility to dysrhythmias, especially in patients with cardiac disease or those on digoxin. Therefore magnesium levels should be monitored and replaced as indicated to prevent complications from electrolyte depletion.
Category reason: This is a nursing monitoring and replacement question focused on preventing complications from diuretic-induced electrolyte losses, which fits Fluid and Electrolyte Imbalances under Physiological Adaptation.

Question 15

A patient with metabolic acidosis is admitted. Which of the following laboratory values would the nurse expect to find in this patient?

Accepted Answer

Answer reason: Metabolic acidosis is characterized by a decreased blood pH (

Question 16

A nurse is assessing a client with heart failure who is taking furosemide. Which finding is most concerning?

Accepted Answer

Answer reason: Furosemide is a loop diuretic that can cause significant potassium loss, and this level indicates hypokalemia. Hypokalemia increases risk for dangerous dysrhythmias, especially in clients with cardiac disease, and may also cause muscle weakness and cramps. This finding requires prompt intervention (e.g., electrolyte replacement and evaluation for ECG changes) and possible adjustment of diuretic therapy.
Category reason: This question tests recognition of a high-risk electrolyte abnormality caused by diuretic therapy and prioritizing the most concerning assessment finding in a patient-care context, which aligns with Fluid and Electrolyte Imbalances.

Question 17

A nurse is caring for a client with heart failure. Which dietary instruction is most appropriate?

Accepted Answer

Answer reason: Sodium restriction reduces water retention and helps decrease preload and congestion, improving symptoms like edema and dyspnea in heart failure. Increasing fluids can worsen volume overload unless a specific fluid goal is prescribed. Avoiding high-potassium foods is not routinely indicated and may be harmful if the client is on diuretics that lower potassium. Large meals can increase oxygen demand and discomfort; smaller, more frequent meals are often better tolerated.
Category reason: This item tests a nursing care decision about diet teaching to prevent worsening fluid overload and related complications in a client with heart failure, which is a patient-care intervention within Physiological Adaptation.

Question 18

A laboring diabetic client on insulin drip becomes diaphoretic and shaky; FHR baseline rises to 170. Capillary glucose is 48 mg/dL. What is the priority?

Accepted Answer

Answer reason: The client has symptomatic hypoglycemia (diaphoresis, shakiness) with a critically low glucose of 48 mg/dL, which is an immediate maternal emergency. Rapid correction with IV dextrose is indicated in a laboring patient on an insulin infusion because it provides the fastest, reliably absorbed glucose source. Maternal hypoglycemia and adrenergic stress can contribute to fetal tachycardia, so treating the mother is the priority to stabilize both maternal status and fetal response. Increasing insulin or restricting intake would worsen hypoglycemia, and oxytocin is not appropriate until stabilization.
Category reason: This is a priority nursing intervention for an acute metabolic instability (symptomatic hypoglycemia) requiring immediate action and protocol-based treatment, which fits NCLEX-focused physiologic adaptation management.

Question 19

A patient with acute kidney injury has the following lab results: BUN 68 mg/dL, Creatinine 4.5 mg/dL, K 6.2 mEq/L. The nurse’s priority action is?

Accepted Answer

Answer reason: A potassium of 6.2 mEq/L is severe hyperkalemia and poses an immediate risk for life-threatening dysrhythmias. Continuous ECG monitoring is the fastest nursing action to detect conduction changes early while other treatments are being arranged. Giving a diuretic or restricting dietary intake may be part of management but does not address the immediate arrhythmia risk, and the provider can be notified after initiating safety monitoring.
Category reason: This item tests nursing prioritization and immediate safety actions in response to a critical electrolyte abnormality, which aligns with NCLEX-style management of fluid and electrolyte imbalances.

Question 20

During the early postoperative period after thyroidectomy which of the following findings is a cause of concern?

Accepted Answer

Answer reason: This suggests latent tetany (Trousseau sign) from hypocalcemia, which can occur after thyroidectomy due to inadvertent removal/trauma of the parathyroid glands. Acute hypocalcemia can progress to laryngospasm, seizures, and dysrhythmias, making it an urgent postoperative concern requiring prompt assessment of calcium and possible IV calcium replacement. In contrast, mild sore throat and incisional pain are expected early findings, and a low-grade postoperative fever may occur but is typically less immediately dangerous than signs of hypocalcemia.
Category reason: This is a postoperative nursing assessment question focused on identifying a dangerous complication (hypocalcemia) and the need for urgent monitoring/intervention, which aligns with NCLEX Physiological Adaptation and fluid/electrolyte imbalance complications.

Question 21

The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

Accepted Answer

Answer reason: d. Serum potassium 6 mEq/L In acute renal failure, impaired potassium excretion can rapidly cause hyperkalemia, which is immediately life-threatening due to risk of fatal cardiac dysrhythmias. A potassium of 6 mEq/L is above normal and warrants urgent provider notification and cardiac monitoring. The other values can be abnormal in renal failure but are generally less immediately dangerous than significant hyperkalemia in the absence of additional critical findings.
Category reason: This item asks which laboratory abnormality requires immediate reporting for a patient condition, emphasizing urgent clinical judgment about electrolyte-related risk and potential emergency intervention—best aligned with NCLEX Physiological Adaptation focusing on Fluid and Electrolyte Imbalances.

Question 22

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 signs would the nurse expect to note in this client if excess fluid volume is present?

Accepted Answer

Answer reason: Excess fluid volume increases intravascular volume, raising preload and often elevating blood pressure. In heart failure, this volume overload also contributes to pulmonary congestion, consistent with dyspnea and crackles. Additional expected findings typically include weight gain, distended neck veins, and increased CVP, making the other options inconsistent with fluid excess.
Category reason: This question tests nursing recognition of assessment findings associated with fluid volume overload in a heart failure client, which aligns with Fluid and Electrolyte Imbalances within Physiological Adaptation.

Question 23

A 7-year old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider?

Accepted Answer

Answer reason: D. Serum potassium of 3.0 mg/dL Ongoing vomiting and nasogastric suction cause loss of gastric fluid and electrolytes, placing the child at high risk for hypokalemia. A potassium level this low is clinically urgent because it can precipitate dysrhythmias, muscle weakness, and worsening ileus, requiring prompt provider notification and replacement planning. The other findings are not as immediately dangerous: pH 7.45 is within normal range, and the listed intake/output amounts are not inherently alarming without additional context of weight, trends, and losses.
Category reason: This question asks the nurse to identify and report a dangerous electrolyte abnormality in a child with vomiting/NG suction, which is a patient-care safety judgment focused on fluid and electrolyte complications.

Question 24

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances?

Accepted Answer

Answer reason: In the diuretic phase of acute kidney injury, recovering nephrons produce large volumes of dilute urine but cannot yet conserve electrolytes effectively. This leads to urinary loss of sodium and potassium, creating risks for low serum sodium and low serum potassium. Ongoing diuresis can also cause volume depletion, further worsening electrolyte derangements and hemodynamic instability. Close monitoring guides timely replacement and prevents dysrhythmias and neurologic complications.
Category reason: This item tests nursing monitoring and recognition of electrolyte complications during a specific phase of AKI, which is a patient-care safety judgment within fluid and electrolyte management.

Question 25

A 1-year-old child is admitted with dehydration due to vomiting and diarrhea. Which assessment finding is most concerning?

Accepted Answer

Answer reason: A markedly prolonged capillary refill indicates poor peripheral perfusion from hypovolemia and can be an early sign of impending shock in infants and toddlers. This finding reflects compromised circulation rather than just mild-to-moderate dehydration. While dry mucous membranes, tachycardia, and a sunken fontanel are consistent with dehydration, they are generally less specific for critical perfusion failure than severely delayed refill. This warrants rapid escalation of care and aggressive rehydration per protocol.
Category reason: This item tests nursing assessment and recognition of the most urgent sign of worsening dehydration/hypovolemia requiring prompt intervention, fitting Fluid and Electrolyte Imbalances under Physiological Adaptation.

Question 26

A 32-year-old male presents with profuse, watery diarrhoea described as "rice water stools," dehydration, and muscle cramps. Which of the following is the best initial management?

Accepted Answer

Answer reason: The priority in cholera-like secretory diarrhea is rapid correction of severe dehydration and electrolyte losses, which can quickly lead to hypovolemic shock and life-threatening hypokalemia. Muscle cramps support significant electrolyte depletion, making immediate rehydration (oral rehydration solution or IV fluids depending on severity) the key first step. Antibiotics can reduce duration and stool volume but are adjuncts after stabilization; antimotility drugs are generally avoided, and surgery is not indicated.
Category reason: This question tests the immediate, priority intervention to manage dehydration and electrolyte loss from acute profuse diarrhea, which is a patient-care stabilization decision under fluid and electrolyte imbalances.

Question 27

A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings as a manifestation of fluid volume excess?

Accepted Answer

Answer reason: Fluid volume excess increases venous return and central venous pressure, which can manifest as jugular venous distention on assessment. This finding is especially relevant in clients receiving IV fluids because overly rapid or excessive infusion can precipitate hypervolemia. In contrast, decreased bowel sounds and bilateral muscle weakness are more consistent with electrolyte disturbances, and a thready pulse is more typical of hypovolemia/shock states rather than fluid overload.
Category reason: This item tests recognition of assessment findings indicating hypervolemia in the context of IV therapy, which is a fluid and electrolyte imbalance requiring nursing assessment and clinical judgment.

Question 28

A nurse is caring for a client who has hyponatremia and is receiving an infusion of a prescribed hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is effective?

Accepted Answer

Answer reason: Hyponatremia can cause cerebral edema and neurologic changes such as confusion, lethargy, and decreased level of consciousness. Hypertonic saline raises serum sodium and draws water out of brain cells, reducing cerebral edema and improving neurologic status. Therefore, a clearer mental status is a direct indicator that sodium correction is having the intended physiologic effect. The other options are less specific to hyponatremia treatment response (e.g., Chvostek’s sign relates more to hypocalcemia).
Category reason: This item asks the nurse to evaluate effectiveness of hypertonic saline for hyponatremia by assessing a clinical response, which is nursing management of a fluid and electrolyte imbalance.

Question 29

A nurse is providing education about dietary modifications to the parent of a school age child who has glomerulonephritis. Which of the following information should the nurse include in the teaching?

Accepted Answer

Answer reason: Glomerulonephritis commonly causes impaired renal excretion of sodium and water, leading to edema and hypertension. Restricting dietary sodium helps reduce fluid retention and supports blood pressure control. Other dietary changes may be individualized (e.g., protein or potassium adjustments depending on renal function), but sodium restriction is a core teaching point for managing volume overload.
Category reason: This item tests a nursing dietary intervention to manage fluid retention/edema and hypertension from renal inflammation, aligning with managing fluid and electrolyte imbalance in Physiological Adaptation.

Question 30

Rehydration Therapy Question. 1 A 4-year-old child presents with severe diarrhoea and signs of dehydration, including sunken eyes and lethargy. What is the most appropriate initial step in managing this patient?

Accepted Answer

Answer reason: Severe dehydration with lethargy indicates significant intravascular volume depletion and risk of hypovolemic shock, so rapid isotonic fluid resuscitation is the priority. Oral rehydration is appropriate for mild-to-moderate dehydration but may be inadequate or unsafe initially when perfusion is compromised or mental status is depressed. Broad-spectrum antibiotics are not routine unless specific bacterial indications are present (e.g., dysentery/cholera suspicion), and antidiarrheals like loperamide are generally avoided in young children due to safety concerns and potential worsening of illness.
Category reason: This question tests the nurse’s initial management and prioritization of fluid resuscitation for dehydration in a pediatric patient, which is a patient-care intervention focused on correcting fluid volume deficit.

Question 31

A nurse is caring for a newborn who is jittery, has a weak cry, and a blood glucose level of 35 mg/dL. What is the priority nursing action?

Accepted Answer

Answer reason: D. Feed the newborn with formula or breast milk A blood glucose of 35 mg/dL with symptoms (jitteriness, weak cry) indicates clinically significant neonatal hypoglycemia requiring immediate correction. The fastest appropriate first-line nursing intervention for a stable newborn is prompt enteral feeding to raise glucose and prevent progression to seizures or neurologic injury. Warming can reduce ongoing glucose consumption but does not correct the low glucose as quickly as feeding. Provider notification is important, but treatment should not be delayed while waiting for orders if feeding is feasible and the infant is able to tolerate it.
Category reason: This is a priority nursing intervention question focused on immediate management of a physiologic instability (symptomatic neonatal hypoglycemia) to prevent deterioration, which aligns with Physiological Adaptation.

Question 32

A client with hyponatremia (Na+ 120 mEq/L) is at risk for which complication?

Accepted Answer

Answer reason: A) Muscle weakness and seizures Severe hyponatremia lowers plasma osmolality, causing water to shift into brain cells and increasing the risk of cerebral edema. Neurologic deterioration can progress from headache and confusion to seizures and coma, making seizures a key life-threatening complication at Na+ 120 mEq/L. Skeletal muscle weakness can also occur due to impaired neuromuscular function in low sodium states. The other options align more with different electrolyte disturbances (e.g., hyperreflexia with hypocalcemia; flushed skin/polyuria with hypercalcemia).
Category reason: This question tests recognition of clinical complications and nursing concerns related to an electrolyte abnormality (hyponatremia), which fits Fluid and Electrolyte Imbalances under Physiological Adaptation.

Question 33

A nurse is caring for a client who is febrile (High fever). To reduce the client’s fever, the nurse applies a cooling blanket. Which of the following findings indicates the client is having an adverse reaction to the cooling?

Accepted Answer

Answer reason: Shivering is a compensatory response to cold exposure that increases metabolic heat production and oxygen demand, which can worsen physiologic stress in a febrile client. It also counteracts the intended cooling effect, making the intervention ineffective and potentially precipitating hypothermia. When shivering occurs, the cooling method should be adjusted (e.g., reduce cooling intensity and add light covering) and the client reassessed.
Category reason: This question tests nursing recognition of an unsafe physiologic response to a therapeutic cooling intervention and the need to identify a complication during treatment, which is a Physiological Adaptation focus.

Question 34

A nurse is caring for a client with hyperparathyroidism and notes that the client’s serum calcium level is 13 mg/dL. Which medication should the nurse prepare to administer as prescribed for the client?

Accepted Answer

Answer reason: A calcium of 13 mg/dL indicates clinically significant hypercalcemia, which can cause neuromuscular weakness, GI symptoms, and dysrhythmias and requires prompt lowering of serum calcium. Calcitonin decreases serum calcium by inhibiting osteoclast-mediated bone resorption and increasing renal calcium excretion, producing a relatively rapid reduction while other longer-acting therapies are arranged. Calcium chloride and calcium gluconate would worsen hypercalcemia and are used for hypocalcemia. High-dose vitamin D increases intestinal calcium absorption and would further elevate calcium levels.
Category reason: This question tests the nurse’s action in preparing an appropriate medication to treat an electrolyte disturbance (hypercalcemia) in a client scenario, aligning with Fluid and Electrolyte Imbalances under Physiological Adaptation.

Question 35

A nurse is assessing a client with chemotherapy-induced nausea. Which assessment finding requires immediate intervention?

Accepted Answer

Answer reason: This finding indicates potential hypovolemia and evolving electrolyte/acid–base disturbances, which can quickly become life-threatening if not treated. Ongoing emesis also increases risk for acute kidney injury and hemodynamic instability, especially in an immunocompromised chemotherapy patient. Immediate nursing actions include assessing vital signs and hydration status, initiating/maintaining IV fluids as ordered, administering antiemetics, and monitoring intake/output and relevant labs.
Category reason: This item tests nursing judgment about urgency and risk recognition (dehydration from vomiting) and the need for prompt intervention to prevent complications, aligning with NCLEX Physiological Adaptation focused on fluid and electrolyte imbalance.

Question 36

In hypoglycemic patient after giving oral glucose syrup, when will you check next General Random Blood Sugar (GRBS)?

Accepted Answer

Answer reason: Rechecking capillary glucose about 15 minutes after giving fast-acting oral glucose is recommended because it allows sufficient time for intestinal absorption and blood glucose rise. Checking earlier may falsely suggest treatment failure and prompt unnecessary repeat dosing. If the glucose remains low or symptoms persist, another dose of fast-acting carbohydrate is given and glucose is rechecked at similar intervals. This timing supports safe, standardized management and reduces risk of recurrent hypoglycemia.
Category reason: This item tests a nursing intervention and monitoring timeframe after treating hypoglycemia, which is clinical patient-care decision-making aligned with Physiological Adaptation.

Question 37

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are written. Which serum laboratory value warrants the most immediate intervention by the nurse?

Accepted Answer

Answer reason: This level represents severe hypokalemia, which can rapidly precipitate life-threatening ventricular dysrhythmias and respiratory muscle weakness. In DKA, initiating insulin drives potassium into cells and can further lower serum potassium, worsening the danger. Therefore potassium replacement and cardiac monitoring are urgent before or alongside insulin therapy. The other values are expected in DKA/UTI and are less immediately lethal than profound hypokalemia.
Category reason: This question tests prioritization of urgent nursing action based on an electrolyte abnormality in an acute condition (DKA), which aligns with managing fluid and electrolyte imbalances in Physiological Adaptation.

Question 38

A recommended intervention for muscle cramps is?

Accepted Answer

Answer reason: Muscle cramps during hemodialysis are most commonly caused by excessive fluid removal leading to intravascular volume depletion and reduced muscle perfusion. Stopping ultrafiltration addresses the primary cause by halting further volume loss and helping restore circulating volume, which usually relieves cramping. Heat-based measures may provide symptomatic comfort but do not correct the underlying hemodynamic problem and can delay appropriate intervention. Discontinuing treatment only when minimal time remains is not the standard first action because cramps can occur at any point and require prompt correction of the precipitating factor.
Category reason: This question focuses on an appropriate nursing intervention for an acute complication related to fluid removal (ultrafiltration) during a treatment, requiring clinical judgment about managing a physiologic response.

Question 39

Which is a sign of dehydration?

Accepted Answer

Answer reason: Dehydration reduces total body water and salivary secretions, producing dry mucous membranes (e.g., a dry tongue) and thirst. Edema more commonly reflects fluid excess or third spacing rather than simple dehydration. Bradycardia is not a typical early dehydration finding; tachycardia is more expected as volume falls. Hypertension is not characteristic; dehydration more often leads to orthostatic hypotension and low blood pressure as intravascular volume decreases.
Category reason: This item tests recognition of a clinical sign related to body fluid deficit, which fits nursing assessment of fluid and electrolyte imbalance.

Question 40

What is the best indicator of fluid balance?

Accepted Answer

Answer reason: Daily measurement reflects small net gains or losses of body water and is the most sensitive, objective bedside marker for overall fluid status when taken at the same time each day with the same scale and similar clothing. Skin turgor is unreliable in older adults and can be affected by poor elasticity. Blood pressure can remain normal until significant volume change occurs and is influenced by pain, medications, and autonomic responses. Urine color varies with diet, medications, and concentration and is less accurate than weight trends.
Category reason: This item tests nursing assessment of overall hydration/volume status and monitoring for imbalance, which aligns with Fluid and Electrolyte Imbalances under Physiological Adaptation.

Question 41

A client with a new diagnosis of Crohn’s disease reports severe abdominal pain and frequent diarrhea. Which nursing intervention is the priority?

Accepted Answer

Answer reason: Severe diarrhea places the client at immediate risk for dehydration, hypovolemia, and electrolyte disturbances (e.g., hypokalemia), which can rapidly become life-threatening if unrecognized. Priority nursing care follows ABCs and physiologic stability by first assessing for signs of volume depletion, monitoring intake/output, vitals, mucous membranes, and relevant labs. Medications and teaching are important but should follow stabilization and assessment of potential complications from fluid losses. Preparing for colonoscopy is not the urgent priority in the presence of severe symptoms and possible dehydration.
Category reason: This is a patient-care prioritization question requiring nursing judgment to prevent complications from acute diarrhea and abdominal pain, aligning with NCLEX Physiological Integrity and risk reduction via assessment for fluid/electrolyte imbalance.

Question 42

Which of the following is the most important treatment of patients with Dengue H-f ever?

Accepted Answer

Answer reason: Dengue hemorrhagic fever can cause capillary leak and plasma volume loss, leading to hypovolemia and shock. The most crucial immediate management is careful fluid resuscitation to restore intravascular volume and maintain perfusion. Antipyretics and limiting movement may be supportive but do not address the life-threatening circulatory compromise. Local measures for bleeding (e.g., ice) are not definitive and do not prevent progression to shock.
Category reason: This question focuses on prioritizing a life-saving clinical intervention (fluid replacement) for an acute infectious illness with risk of hypovolemic shock, which is a patient-care decision under Physiological Adaptation and fluid/electrolyte management.

Question 43

Scenario: A patient with renal failure has serum potassium 6.5 mEq/L. What ECG change is most concerning?

Accepted Answer

Answer reason: At a potassium level of 6.5 mEq/L, hyperkalemia can rapidly precipitate malignant dysrhythmias due to impaired cardiac membrane excitability. Early ECG manifestations classically include tall, narrow, “tented” T waves, which signal clinically significant potassium toxicity that can progress to PR prolongation, QRS widening, sine-wave pattern, and cardiac arrest. U waves are associated with hypokalemia, and ST depression is more consistent with ischemia rather than the primary electrolyte effect here. Sinus bradycardia can occur but is less specific and not the hallmark early warning sign compared with the characteristic T-wave change.
Category reason: This question tests recognition of ECG effects of an electrolyte disturbance (hyperkalemia) and associated acute risk, which aligns with nursing clinical judgment for managing fluid and electrolyte imbalances.

Question 44

Nina, then 2nd child is diarrhea for 5 days. There is no blood in the stool. She is irritable, and her eyes are sunken. The nurse offered fluids and and she child drinks eagerly. How would you classify Nina’s illness?

Accepted Answer

Answer reason: The findings of irritability and sunken eyes indicate dehydration, but the child is still able to drink and does so eagerly, which argues against severe dehydration (where the child is typically unable to drink or drinks poorly and may be lethargic/unconscious). The absence of blood in stool rules out dysentery by definition. Therefore, the overall clinical picture best fits moderate/some dehydration rather than no dehydration or severe dehydration.
Category reason: This item asks the nurse to classify dehydration severity in a pediatric diarrhea scenario using clinical assessment signs, which is a patient-care judgment about fluid status and risk.

Question 45

Which lab value is most important to monitor in a client receiving furosemide (Lasix)?

Accepted Answer

Answer reason: Furosemide is a loop diuretic that increases urinary excretion of electrolytes, especially potassium, placing the client at high risk for hypokalemia. Low potassium can precipitate dangerous dysrhythmias and potentiate digoxin toxicity, making it a key safety monitoring priority. Monitoring potassium also guides replacement therapy and evaluation of symptoms such as muscle weakness or cramps.
Category reason: This question tests nursing monitoring for a medication-associated electrolyte complication, aligning with Fluid and Electrolyte Imbalances under Physiological Adaptation.

Question 46

Scenario: A patient with 40% TBSA burns is receiving fluid replacement. What parameter best indicates effective fluid resuscitation?

Accepted Answer

Answer reason: Urine output is the most reliable bedside indicator of adequate organ perfusion and effective intravascular volume restoration during burn resuscitation. In adults, targeting at least 0.5 mL/kg/hr reflects sufficient renal perfusion and cardiac output after major fluid shifts from capillary leak. Blood pressure and heart rate can remain abnormal from pain, stress response, or ongoing hypovolemia and are less specific early markers. Respiratory rate is nonspecific and can be influenced by pain, anxiety, or inhalation injury.
Category reason: This question tests nursing evaluation of response to IV fluid therapy after major burns, focusing on monitoring perfusion and resuscitation effectiveness, which aligns with managing fluid volume status within Physiological Adaptation.

Question 47

A client with Cushing's syndrome is on fluid restriction. Which assessment is most concerning?

Accepted Answer

Answer reason: These findings suggest fluid volume excess with possible pulmonary edema, which is a high-priority complication. In Cushing’s syndrome, excess cortisol causes sodium and water retention, increasing the risk for hypervolemia even with prescribed restriction. Crackles indicate fluid in the alveoli and weight gain reflects acute fluid accumulation, both requiring prompt intervention. Mild thirst and decreased urine output can occur with restriction and are less immediately dangerous when compared with respiratory compromise.
Category reason: This question asks the nurse to identify the most concerning assessment finding related to fluid status and potential complications (pulmonary edema), requiring clinical nursing judgment about fluid overload.

Question 48

A client is admitted with Addisonian crisis after vomiting for 3 days. Which lab findings are a priority to monitor?

Accepted Answer

Answer reason: C. Sodium and potassium levels Addisonian crisis causes mineralocorticoid deficiency leading to life-threatening hyponatremia and hyperkalemia with dehydration and hypotension, and vomiting further worsens fluid and electrolyte losses. Potassium elevation can precipitate dysrhythmias, making rapid identification and correction critical. Sodium derangements contribute to neurologic changes and shock, so trending these values guides urgent IV fluids and steroid therapy.
Category reason: This question asks the nurse which monitoring is the priority during an adrenal crisis, emphasizing urgent prevention of complications from electrolyte disturbances and shock, which aligns with fluid and electrolyte imbalances in Physiological Adaptation.

Question 49

A client with SIADH is being treated with fluid restriction and sodium replacement. What is the key nursing observation?

Accepted Answer

Answer reason: C. Decreased level of consciousness SIADH causes water retention leading to dilutional hyponatremia, and neurologic changes are the most critical indicators of worsening cerebral edema. A declining level of consciousness can signal severe hyponatremia and impending seizures, requiring urgent reassessment and adjustment of therapy. In contrast, weight loss and polyuria are inconsistent with SIADH (which typically causes weight gain and concentrated urine), and hypoglycemia is not a primary feature.
Category reason: This question focuses on nursing monitoring for complications of an electrolyte disturbance (hyponatremia) in SIADH, which aligns with Fluid and Electrolyte Imbalances under Physiological Adaptation.

Question 50

A nurse inadvertently infuses an IV solution containing potassium chloride too rapidly. Which of the following is an appropriate intervention advised by the physician?

Accepted Answer

Answer reason: Rapid IV potassium chloride can precipitate acute hyperkalemia with life-threatening dysrhythmias. IV regular insulin shifts potassium intracellularly by stimulating the Na+/K+-ATPase, and dextrose is co-administered to prevent hypoglycemia. Rapid isotonic fluids (NS or Ringer's) may support perfusion but do not promptly lower serum potassium, and albumin is not a treatment for hyperkalemia.
Category reason: This item tests an urgent nursing/medical intervention for an electrolyte-related medication error (acute hyperkalemia), requiring patient-care judgment in managing complications, which aligns with Physiological Adaptation → Fluid and Electrolyte Imbalances.

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