Electrolyte imbalances S.G Test 2-DONE

Question 1

1. Manifestations of hypovolemia/fluid volume deficit (pp slide 18)

Answer 1

Most common fluid imbalance
-thirst, dry mucus membranes
-decreased urine output/concentrated urine
-cold clammy skin
-decreased turgor
-decreased capillary refill
-Postural hypotension, tachycardia, tachypnea
-weakness, dizziness
-thready pulse
-weight loss
-Seizures, coma-shock

Question 2

1. Labs for hypovolemia(pp slide 18)

Answer 2

-increased HCT
-increased BUN
-Urine specific gravity > 1.030

Question 3

1. Nursing education for hypovolemia , nursing actions (pp slide 18)

Answer 3

Nursing education:
-drink 8 glasses/day
-respond to thirst
-avoid caffeine & alcohol

Nursing Actions:
-monitor I &o’s, monitor weight
-monitor electrolytes
-administer ordered hydration therapy
-watch position changes

Question 4

Manifestations for HYPERvolemia, labs(pp slide 22)

Answer 4

SIADH monitor for hypervolemia manifestations
-weight gain (most common)
-jugular vein distention
-peripheral & pulmonary edema (crackles in lungs)
-Increase BP
-Dyspnea
-Muscle spasms
-Seizures, coma

LABS:
Decreased HCT; low specific gravity

Question 5

Nursing actions for HYPERvolemia(pp slide 23)

Answer 5

-Administer diuretics as ordered
-Fluid restriction as ordered
-restrict sodium intake
-removal of fluid to treat ascites or pleural effusion
-If dysphasia or Orthopnea> Semi- Fowler’s
-Strict I & O, lung sounds, daily weight, degree of edema reposition every 2 hrs
-Promote rest & diuresis
-Inspect skincare

Question 6

Causes of HYPERvolemia

Answer 6

-Liver failure
-renal failure
- cirrhosis
-cardiovascular

Question 7

2. Risks/causes of hypokalemia (PP slide 15)

Answer 7

-loss of K+ via the kidneys or GI tract: N/V/D
-increased shift of K+ from ECF to ICF
- dietary K+ (rare)
-Renal losses from diuretics, corticosteroids

*Corticosteroids & potassium wasting diuretics (furosemide) = main cause for hypokalemia

Question 8

3. manifestations of hypokalemia (wk4 pp slide 16)

Answer 8

Potassium <3.5
-muscle weakness
-U wave
-decreased GI: ileus
-Hyporeflexia
-shallow breathing
-weak irregular pulse
-fatigue

Question 9

4. risks/causes of hyperkalemia (pg.186)

Answer 9

-ace inhibitors
-IV potassium (too much)
-renal failure
-severe burns/crushing injuries
-potassium-sparing diuretics
-overuse of potassium supplements
-salt substitutes
-potassium-rich foods
-Addison’s disease
-rapid administration of parental potassium salts

Question 10

Manifestations of hyperkalemia: (pp slide 13)

Answer 10

-Potassium >5.0 mEq/L
-abdominal cramps
-diarrhea
-restlessness
-hypotension, bradycardia, Arrhythmia
-muscle weakness
-increased DTR(deep tendon reflex)
-Tall peaked T waves
-Seizures

Question 11

5. laboratory data for hyponatremia (pp slide 10)

Answer 11

Sodium <135 mEq/L
Addison’s disease
Sodium & Chloride go together

Question 12

Manifestations for hyponatremia (pp slide 10)

Answer 12

-mental confusion
-muscular weakness
-elevated temp.
-tachycardia
-weak, thready pulses
-respiratory arrest

Question 13

Priority interventions for hyponatremia (pp slide 10)

Answer 13

-Assess airway
-reduce diuretic dosage
-fluid restriction
-hypertonic solution (3% or 5% NaCI)

Question 14

6. manifestations of hypernatremia (pp slide 8)

Answer 14

-sodium >145 mEq/L
Cushing’s syndrome
-extreme thirst
-dry flushed skin
-low grade fever
-Orthostatic Hypotension
- decreased level of consciousness

Late signs:
-Red beefy tongue
-n/v
-increased muscle tone (twitching)

Question 15

Priority nursing interventions for hypernatremia (pp slide 8)

Answer 15

-prevent dehydration/replace fluids
-sodium restriction
-diuretics (promote sodium excretion)
-hypotonic solution (0.225% or 0.45%NaCL)

Question 16

7. manifestations of hypocalcemia (pp slide 22)

Answer 16

-Calcium <9.0 mg/dL
-muscle spasms
-circumoral tingling
-increased DTR
-diarrhea
-decreased bone density: risk for fractures
-Tetany : +Chvostek’s Sign & +Trousseu’s sign
-ECG changes
-Low HR/BP (when severe)

Question 17

Priority nursing interventions for hypocalcemia (pp slide 22)

Answer 17

Oral & IV replacement of calcium
-seizure precautions: avoid overstimulation

Question 18

8. manifestations of hypermagnesemia (pp slide 26)

Answer 18

-facial flushing
-lethargy
-hypotension
-low HR
-decreased bowel sounds
-impaired deep tendon reflexes
-muscle paralysis
-respiratory & cardiac arrest

Question 19

Common Causes of electrolyte imbalances for the older adult

Answer 19

-decreased kidney function
-unbalanced nutrition
-laxative use
-decrease of total body water

Question 20

Third Spacing & Manifestations

Answer 20

You cant measure fluid loss w/third spacing
Manifestations:
-Weight gain
-decreased urinary output
-HTN, tachycardia

Question 21

LAB VALUES:

Answer 21

Potassium: 3.5-5.0
Calcium: 9-11
Magnesium: 1.5- 2.5
Phosphate: 2.5- 4.5
Sodium: 135-145
Chloride: 95-105

Question 22

Dehydration need to know

Answer 22

-decreased skin turgor
-increased urine specific gravity
-decreased urinary output
-thirst
-increased HCT, Increased specific gravity, increased BUN
-diarrhea, n/v