Fluid & Electrolytes
NCLEX® practice.

Free practice set · 2 questions

2 more free fluid & electrolytes NCLEX-RN® practice questions

Real questions from the same bank the app serves. Pick an answer in your head, then open the rationale to see why the correct option holds and why each other option falls short. No account needed for these.

1. Question 1 of 2 · Fluid & Electrolyte Imbalances

   A 68-year-old client recovering from a left-sided stroke is admitted to the medical-surgical unit. Pre-stroke, the client was fully independent with all ADLs and instrumental ADLs, living alone in a single-story home. Current assessment reveals right-sided weakness, intact cognition (alert and oriented ×3), and intact swallow. The client ambulates with a hemi-walker and contact guard assistance due to impaired left-side balance. This morning, the client attempts to bathe independently but struggles to lift the left arm into the wash cloth and reach the left side of the back. The client becomes frustrated but does not request help.

   1. AAssign the nursing assistant to assess the client's bathing ability and document the findings so you can plan discharge-day ADL retraining with occupational therapy.
   2. BComplete the entire bath for the client immediately, since the client is struggling and is now post-stroke, and reassess tolerance for self-care in 48 hours.
   3. CAssess the client's perceived barriers to the task; provide a tub bench and long-handled sponge so the client can complete as much of the bath as safely possible while you assist with the unreachable areas.
   4. DRecognize the frustration as a sign of post-stroke confusion and contact the family to discuss long-term placement options before the client attempts any further ADLs unsupervised.
   Show the answer and rationale

   Correct answer: C. Assess the client's perceived barriers to the task; provide a tub bench and long-handled sponge so the client can complete as much of the bath as safely possible while you assist with the unreachable areas.

   Prioritizing autonomy and functional restoration is appropriate because the client is alert, cognitively intact, and was independent pre-stroke. Although the client now has left-side weakness, graded assistance and environmental adaptation, such as a tub bench and long-handled sponge, allow the client to perform every step of the bath that can be safely completed, while the nurse provides targeted assistance only for the unreachable areas, such as the left back and left arm. This approach preserves existing capability, prevents deconditioning, and maintains dignity while building toward future independence. Taking over the entire bath the moment the client struggles accelerates learned helplessness and deconditioning, which is particularly harmful for a stroke survivor who needs graded practice to regain function. Frustration should not be interpreted as confusion because the client is alert and oriented with intact cognition, and frustration during a physical challenge is an expected emotional response, not a sign of cognitive impairment. Treating refusal or frustration as confusion without first screening for pain, fatigue, or task barriers inappropriately escalates the situation and violates the autonomy principle. A complex post-stroke ADL assessment should not be delegated to assistive personnel or deferred until discharge. Assessments of new deficits and safety screens cannot be delegated to UAPs, and ADL retraining must begin at bedside while the client is still hospitalized so there is adequate time to practice and the team can evaluate functional response before discharge.

   A. Assign the nursing assistant to assess the client's bathing ability and document the findings so you can plan discharge-day ADL retraining with occupational therapy.

   Incorrect. This option violates the correct-scope rule by delegating a complex post-stroke ADL assessment to assistive personnel. Assessment of a new deficit and the specific safety screen for bathing cannot be delegated; only task execution by the UAP after the RN's assessment is appropriate. Deferring ADL retraining until discharge also violates the timing rule; practice must begin at bedside immediately so the client has time to adapt and the team can evaluate response.

   B. Complete the entire bath for the client immediately, since the client is struggling and is now post-stroke, and reassess tolerance for self-care in 48 hours.

   Incorrect. This option violates the maximize-capability-before-substituting rule by taking over the entire bath at the first sign of struggle. The client retains the cognitive capacity and physical ability to complete much of the bath safely; full substitution accelerates deconditioning and learned helplessness, particularly harmful after stroke when graded practice is essential for motor recovery.

   C. Assess the client's perceived barriers to the task; provide a tub bench and long-handled sponge so the client can complete as much of the bath as safely possible while you assist with the unreachable areas.

   Correct. This option maximizes the client's existing capability by allowing the client to perform every safe step of the bath while providing only the smallest amount of assistance for the left-side areas the client cannot reach due to weakness. Adaptive equipment (tub bench, long-handled sponge) and contact-guard supervision satisfy the safety screen (cognition intact, stable ambulation with device, swallow intact). This approach preserves autonomy, prevents deconditioning, and supports functional restoration appropriate for post-stroke recovery.

   D. Recognize the frustration as a sign of post-stroke confusion and contact the family to discuss long-term placement options before the client attempts any further ADLs unsupervised.

   Incorrect. This option treats frustration as evidence of confusion without first reassessing for pain, fatigue, or task barriers. The client is alert and oriented ×3; frustration during a physical challenge is a normal emotional response, not a cognitive deficit. Escalating to family and placement discussion without completing a proper assessment violates the autonomy principle and misapplies a capacity-to-refuse workup.

2. Question 2 of 2 · Fluid & Electrolyte Imbalances

   A 68-year-old client with a history of stroke is receiving nutrition via a nasogastric (NG) tube. The tube was placed 3 days ago and verified by chest radiograph. During rounds this morning, the nurse notes the client is alert and responsive, with the head of bed elevated at 35 degrees. The client's last gastric residual was 180 mL (facility threshold 250 mL). As the nurse prepares to administer the scheduled continuous feeding, the client suddenly coughs and reports feeling short of breath. Oxygen saturation drops from 96% to 92%. Which action should the nurse take first?

   1. AAdminister an antiemetic medication and then resume the feeding once the client's nausea subsides.
   2. BLay the client flat to prevent accidental tube dislodgement and observe for respiratory changes over the next 30 minutes.
   3. CStop the feeding infusion immediately and assess for aspiration risk; lower the head of bed if the client becomes uncomfortable.
   4. DContinue the feeding while auscultating over the epigastrium to verify the tube position, then report the cough to the health care provider.
   Show the answer and rationale

   Correct answer: C. Stop the feeding infusion immediately and assess for aspiration risk; lower the head of bed if the client becomes uncomfortable.

   New respiratory cues during feeding, such as sudden cough, dyspnea, and O₂ desaturation, require the feeding to be stopped immediately to prioritize airway safety and prevent aspiration. This action directly applies the aspiration-prevention bundle rule: when a client demonstrates signs of aspiration risk during feeding, the feeding must be held, and assessment must be performed before resumption. The client's elevated HOB (35°), alert mental status, and adequate residual were initially supportive; however, the acute change in respiratory status signals potential aspiration or tube migration and overrides continued administration. Stopping the feed and assessing is the safety-first intervention that protects the airway and allows the nurse to determine whether placement re-verification or additional interventions are needed before safely resuming nutrition. Continuing the feeding while relying on auscultation alone violates the placement-verification rule. Auscultation of an injected air bolus over the epigastrium is no longer an evidence-based method because air sounds can be transmitted if the tube has migrated into the lung, esophagus, or peritoneum. The correct verification method is pH testing of gastric aspirate (≤5.5) or marked-length check at every feeding per facility policy. Additionally, continuing the feeding despite acute aspiration cues violates the aspiration-prevention rule. Treating the finding, cough/dyspnea, with an antiemetic is an unrelated action that does not address the underlying aspiration risk. Antiemetics do not prevent aspiration or confirm safe tube placement. Failing to hold the feeding in response to the acute respiratory change violates the aspiration-prevention rule. Laying the client flat, supine or near-supine, directly contradicts the aspiration-prevention bundle. The rule requires the head of bed to remain elevated 30–45 degrees during and after feeding to reduce the risk of gastric contents aspirating into the airway. Lowering the HOB increases aspiration risk and is contraindicated for clients without an artificial airway.

   A. Administer an antiemetic medication and then resume the feeding once the client's nausea subsides.

   Violates the aspiration-prevention rule by treating with an unrelated action (antiemetic). Antiemetics do not address aspiration risk or verify placement. The acute respiratory change demands immediate feed hold and assessment, not medication and resumption.

   B. Lay the client flat to prevent accidental tube dislodgement and observe for respiratory changes over the next 30 minutes.

   Violates the aspiration-prevention rule by laying the client flat (supine). The rule requires HOB ≥30 degrees during and after feeding. Lowering HOB increases aspiration risk, particularly in clients without an artificial airway, and worsens the existing respiratory compromise.

   C. Stop the feeding infusion immediately and assess for aspiration risk; lower the head of bed if the client becomes uncomfortable.

   Correct. Immediately stopping the feeding and assessing when new aspiration cues appear (cough, dyspnea, O₂ drop) is the key safety action. This satisfies the aspiration-prevention rule: hold the feeding for new aspiration risk and assess before resumption. The initially adequate residual and elevated HOB do not override the acute respiratory change.

   D. Continue the feeding while auscultating over the epigastrium to verify the tube position, then report the cough to the health care provider.

   Violates both placement-verification and aspiration-prevention rules. Auscultation alone is not evidence-based; air sounds can occur with tube in lung, esophagus, or peritoneum. Correct verification requires pH ≤5.5 or marked-length check. Continuing the feeding despite acute cough and O₂ desaturation ignores the aspiration-prevention bundle.