NCLEX Info>>Practice Questions>>
NCLEX Practice Questions on Fluids and Electrolytes
A Multiple Choice Question on Fluids and Electrolytes
Question: A 4 year old child with severe gastroenteritis experienced prolonged nausea and vomiting. Which of the following clinical signs would indicate she had a fluid deficit?
A) Respiration rate of 12 bpmB) Blood pressure of 100/65 mmHg
C) Heart rate of 150 bpm
D) Capillary refill of 0.4 seconds
Answer: A pediatric patient has slightly different ranges of normal for vital signs than an adult. Regardless, a heart rate of 150 bpm indicates hypovolemia. The heart has increased its rate to pump more blood to end organs. The breathing, cap refill, and blood pressure would be normal in a healthy 4 year old girl. Therefore, the correct answer is C.
Topics: Vital signs, Pediatrics, Fluids and electrolytes, Hemodynamics, Alterations in body systems, Gastrointestinal, Med-Surg
Nursing Process: Nursing Process
NCLEX Category: Physiological Adaptation
Nurse Types: RN,LPN
References: Cheever, K. & Hinkle, J. (2014). Fluid and Electrolytes: Balances and Disturbances In Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (pp. 238-240). (13th ed). Philadelphia, Pa: Wolters Kluwer Health | Lippincott Williams & Wilkins.
A Select All That Apply (SATA) Question on Fluids and Electrolytes
Question: A patient is admitted with congestive heart failure (CHF) exacerbation. Which of the following would be appropriate to follow in order to track the progress of inpatient diuresis therapy? Select all that apply.
A) Chest X-rayB) Urine output
C) Blood pressure
D) Peripheral edema
E) D-dimer blood test
F) B-type or brain natriuretic peptide (BNP)
G) Body mass
Answer: In congestive heart failure, there are a number of ways to determine how diuresis is progressing. Chest X-rays provide an assessment of fluid in the lungs, while urine output is a good direct measure of the quantity of fluid expelled by diuresis. Peripheral edema and body mass (weight) could be used to track progress, but they are less sensitive measures - they will not change as dramatically with diuresis. BNP can give a good idea of the stresses placed on the heart and is a useful blood test, especially if the patient’s baseline value is listed in the chart or if BNP was measured on admission. D-dimer blood test is used to detect intravascular coagulation and is not helpful. Blood pressure may not correlate with diuresis and cannot be used. Therefore, the correct answer is ABDFG.
Topics: Cardiovascular, Fluids and electrolytes, Nursing assessment, Med-Surg
Nursing Process: Nursing Process
NCLEX Category: Physiological Adaptation
Nurse Types: RN,LPN
References: Cheever, K. & Hinkle, J. (2014). Management of Patients With Complications From Heart Disease In Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (p. 802). (13th ed). Philadelphia, Pa: Wolters Kluwer Health | Lippincott Williams & Wilkins.