NCLEX Quiz

Answer & Rationale:

Option 1, is Correct

Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or on long-term corticosteroid therapy, or a client receiving frequent wound irrigations, is at risk for fluid volume excess.

Answer & Rationale:

Option 4 , is Correct

Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased CVP, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration (fluid volume deficit) has a low CVP. The assessment findings in options 1, 2, and 3 are seen in a client with fluid volume excess.

Answer & Rationale:

Option 2, is Correct

Rationale: 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. The causes of fluid volume excess include decreased kidney function, congestive heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

Answer & Rationale:

Option 2,3,5,6  is Correct

Rationale: The normal potassium level is 3.5 to 5.1 mEq/L. Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.

Answer & Rationale:

Option 1, is Correct

Rationale: The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. Option 1 is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. Options 2, 3, and 4 are within the normal range.

Answer & Rationale:

Option 4, is Correct

Rationale: A normal platelet count ranges from 150,000 to 400,000 cells/mm3. The nurse should place the report containing the normal laboratory value in the client’s medical record. A platelet count of 300,000 cells/mm3 is not an elevated count. The count also is not low; therefore bleeding precautions are not needed.