Fluid and Electrolyte Content Part 2 Flashcards
What would you expect to see in a patient with fluid volume deficit? SATA
A. Decreased skin turgor
B. Tachycardia
C. Increased BP
D. Weight Gain
E. Moist, pink mucous membranes
Answer: A, B
Define crystalloids vs Colloids
Crystalloids: IV solutions with electrolytes
Colloids: Protein = remains in vascular space
Why is this important?
What labs would you expect to see with fluid volume deficit related to dehydration? SATA
A. H/H: Increased
B. BUN: Decreased
C. Creatinine: Increased
D. Specific Gravity: Increased
Answer: A, D
(Slide 26)
What are the functions of Sodium normally
ECF Osmolarity
Muscle contraction/nerve transmission
What system would you expect to be effected of your sodium is altered?
T/F: A small deviation in electrolyte levels can cause major abnormalities
True
What is the main system we consider when evaluating Potassium levels
Cardiac
A client with a sodium level of 125 might display which clinical manifestations? SATA
A. Muscle cramps
B. Thirst
C. Headaches
D. Seizures
E. Dry mucous membranes
Answer: A, C, D
What CM might you see in a patient with a sodium level of 155? SATA
A. Diarrhea
B. Thirst
C. Dry mucous membranes
D. Decreased reflexes
E. Headache
Answer: B,C,D,E
What would be a priority intervention for a patient with alterations in sodium level?
A. Attach to telemetry monitor
B. Put on a fluid restriction
C. Place on complete bed rest
D. Implement seizure precautions
Answer: D
What would be a priority intervention for a patient with alterations in Potassium level?
A. Attach to telemetry monitor
B. Put on a fluid restriction
C. Place on complete bed rest
D. Implement seizure precautions
Answer: A
What is your major concern with a patient whose calcium levels are 19?
A. Seizure
B. Muscle cramps
C. Cardiac Arrest
D. Nausea
Answer: C
Which electrolyte is affected in (hypo/hyper)kalemia
A. Sodium
B. Potassium
C. Magnesium
D. Calcium
Answer: B
What are appropriate nursing actions for someone with a fluid or electrolyte imbalance? SATA
A. Daily weights
B. Evaluate lab values
C. Ensure urine output of 10mL an hour
D. Assess skin
Answer: A,B,D
What is the most reliable indicator for fluid volume status?
A. Intake and Output
B. Lab Values
C. Daily Weight
D. Edema
Answer: C
On morning assessment of your patient who has severe burns. You notice that fluid is starting to accumulate in his abdomen. You note that his weight has not changed and his intake and output is equal. What do you suspect?
A. Third spacing
B. This is normal and expected after a burn and it is benign
C. Document this finding as non-pitting abdominal edema.
Answer: A
Rationale: Third-spacing is the accumulation of trapped extracellular fluid in a body space
Which patient is at more risk for a fluid/electrolyte imbalance?
A. An 8 month old with a fever of 102.3F and diarrhea
B. A 55 year old diabetic with nausea and vomiting
C. A 5 year old with RSV
D. A healthy 87 year old with intermittent episodes of gout
Answer: A
Rationale: Infants and older adults are at a higher risk of fluid-related problems than any other age group. This is because infants have the highest amount of total body fluid (80% of the body is made up of fluid) and if any type of illness especially GI effects the body this increases the chances of an electrolyte imbalance.
Which patient is at most risk for fluid volume deficit?
A. A patient who has been vomiting and having diarrhea for 2 days.
B. A patient with continuous nasogastric suction.
C. A patient with an abdominal wound vac at intermittent suction.
D. All of the above are correct.
Answer: D
The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving IV fluids. Which assessment data would indicate to the nurse that the dehydration remains unresolved?
A. An oral temperature of 98.8 F
B. A urine specific gravity of 1.043 (elevated)
C. A urine output that is pale yellow
D. A blood pressure of 120/80 mmHg
Answer: B
Rationale: An elevated concentration of urine indicates dehydration
