NACE Fluid and Electrolyte Balance 4

Question 1

A client receiving IV fluids develops pitting edema, crackles in the lungs, and a bounding pulse. Which condition does the nurse suspect?

Accepted Answer

Fluid volume excess

Answer

Pitting edema, pulmonary crackles, and bounding pulse are classic signs of fluid volume excess (hypervolemia).

Question 2

A nurse is caring for a client with a serum potassium of 6.2 mEq/L. Which food should the nurse instruct the client to avoid?

Accepted Answer

Bananas

Answer

Bananas are high in potassium and should be avoided by clients with hyperkalemia.

Question 3

Which clinical finding is most consistent with hypocalcemia?

Accepted Answer

Positive Trousseau's sign

Answer

Trousseau's sign (carpal spasm with BP cuff inflation) is a hallmark of hypocalcemia due to increased neuromuscular excitability.

Question 4

A post-operative client has a urine output of 20 mL/hr for 2 consecutive hours. What is the nurse's priority action?

Accepted Answer

Notify the provider

Answer

Urine output below 30 mL/hr indicates oliguria and possible renal hypoperfusion; the provider must be notified promptly.

Question 5

Which IV fluid is considered isotonic and is most appropriate for replacing extracellular fluid losses?

Accepted Answer

0.9% NaCl

Answer

0.9% NaCl (normal saline) is isotonic and expands extracellular fluid without shifting water into or out of cells.

Nursing Acceleration Challenge Exam (NACE) I PN-RN Practice Test