VN 22 Test 2

Question 1

1. Manifestations of hypovolemia and Labs

Answer 1

 Thirst, dry mucus membranes
 Cold clammy skin
 Decreased skin tumor and decreased capillary refill
 Postural hypotension, tachycardia, Tachypnea
 Thready pulse
 Decreased urine output, concentrated urine
 Weakness, dizziness
 Weight loss (may be weight gain from fluid that is trap)
 Seizures, coma-Shock
Labs: HCT-increased, Specific gravity >1.030, increased BUN

Question 2

1. Education of Hypovolemia

Answer 2

 Drink 8 glassed/ day
 Respond to thirst
 Avoid caffeine and alcohol

Question 3

1. Actions of Hypovolemia

Answer 3

 MonitorI&Os
 Monitor electrolytes
 Administer ordered rehydration therapy
 Monitor weight
 Watch position changes

Question 4

1. Manifestations of hypervolemia

Answer 4

*SIADH monitor for hypervolemia manifestations
 Weight gain is the most common
 Jugular vein distention
 Peripheral edema
 Increase BP (Hypertension)
 Dyspnea (Crackles, Pulmonary edema)
 Muscle spasms
 Seizure, coma
Labs: decreased HCT; low specific gravity

Question 5

1. Nursing Action of hypervolemia

Answer 5

 Administer diuretics as ordered
 Fluid restrictions as ordered
 Restriction of sodium intake
 Removal of fluid to treat ascites or pleural effusion
 If dyspnea or orthopnea> Semi-Fowler’s
 Strict I &O, lung sounds, daily weight, defrocked edema, reposition q 2 hours
 Promotes rest and diuresis
 Inspect skin care

Question 6

1. Nursing actions for fluid imbalance

Answer 6

 Monitor intake and output
 Monitor electrolyte levels
 Auscultate lungs
 Measure weights daily

Question 7

2. Risks/causes of hypokalemia

Answer 7

• Renal losses from diuretics(potassium-wasting diuretic), corticosteroids (NEED TO KNOW)

Question 8

3. manifestations of hypokalemia

Answer 8

 Potassium < 3.5mEq/L
 Muscle Weakness
 U Wave
 Decreased GI: lleus
 Hyporeflexia
 Shallow breathing
 Weak irregular pulse
 Fatigue

Question 9

4. risks/causes of hyperkalemia

Answer 9

-Severe tissue trauma
-Burns
-potassium sparing diuretic: Spironolactone
-Ace inhibitors
-Overdose IV potassium

Question 10

4. Manifestations of Hyperkalemia

Answer 10

 Potassium >0.5 mEq/L
 Abdominal Cramps
 Muscle weakness
 Increased DTR
 Diarrhea
 Hypotension, bradycardia
 Arrhythmias
 Tall, Peaked T waves
 Seizures
 Restlessness

Question 11

5. Manifestations of Hyponatremia

Answer 11

-Sodium <135mEq
-Mental confusion
-Muscle weakness
-Elevated temp
-Tachycardia
- Weak, Thready pulses
- Respiratory arrest

Question 12

5. laboratory data for hyponatremia

Answer 12

Sodium and chloride go together. If one goes the other one goes as well

Question 13

6. manifestations of hypernatremia

Answer 13

 Change (decrease) in level of consciousness
 Sodium > 145mEq/L
 Low grade fever
 Extreme thirst
 Orthostatic hypotension
 Dry flushed skin
 Late signs:
• Red beefy tongue
• Nausea and vomiting
• Increased muscle tone- Twitching

Question 14

6. Priority nursing Intervention of hypernatremia

Answer 14

 Prevent dehydration (replace fluids)
 Sodium Restriction

Question 15

7. Manifestations of Hypocalcemia

Answer 15

 Calcium <9.0 mg/dL
-seizure and coma
 Decreased Bone Density: risk for fx
 Muscle Spasms
 Circumoral tingling
 Tetany
• + Chvostek’s Sign
• + Trousseau’s Sign
 Increased DTR
 Diarrhea

Question 16

7. Considerations for Hypocalcemia

Answer 16

 Seizure Precaution: avoid overstimulation (NEED TO KNOW)
- sodium restrictions

Question 17

8. manifestations of hypermagnesemia

Answer 17

 Hypotension, facial flushing, low HR
 Lethargy
 Decreased bowel sounds
 Impaired (decrease) deep tendon reflex’s
 Muscle paralysis
 Respiratory and cardiac arrest

Question 18

1. Condition that may place a patient at risk for fluid and electrolyte imbalance

Answer 18

-liver problems
-problem in the GI tract
-AKI(Acute renal injury) or renal disease; you will see excessive fluid volume. Kidney problems

Question 19

1. Causes for hypervolemia

Answer 19

-Urinary (renal failure/AKI)
-SIADH ( is important; monitor symptoms for hypervolemia)

Question 20

Third spacing need to know

Answer 20

With third spacing you cannot measure fluid loss

Question 21

The older adults; common cause of electrolyte imbalance

Answer 21

• Decreased kidney function
• Unbalance nutrition
• Laxative use
• Decreases of total body water

Question 22

5. Hyponatremia priority nursing intervention

Answer 22

-Assess airway
-Reduce diuretic dosage