NUR 242 EXAM 2 LATEST UPDATE () |
MED-SURG NURSING | QUESTIONS AND
VERIFIED ANSWERS (A+ GUARANTEE)
Causes of fluid overload - ANSWER✔️•Excessive fluid replacement
•Kidney failure (late phase)
•Heart failure
•Long term corticosteroid therapy
•Syndrome of inappropriate antidiuretic hormone (SIADH)
•Psychiatric disorders with polydipsia
•Water intoxication
s/s fluid overload - ANSWER✔️•CV: tachycardia, bounding pulse, HTN, decrease pulse
pressure, JVD, weight gain
•Resp: increase and shallow resp; SOB, crackles lung sounds
•Skin: pitting edema, skin pale and cool to touch
•Neuromuscular: LOC, HA, visual disturbance, muscle weakness, paresthesia
•GI: increase motility, enlarge liver
,Assessment for fluid overload - ANSWER✔️•Assess risk r/t age and diagnosis, history
(overhydration, CHF, kidney disease)
•Assess vital signs why: watch for bounding tachycardia, HTN, dysrhythmias, tachypnea
•Assess lung sounds (crackles) , weight, LOC, Observe JVD
•Assess lab values: electrolytes imbalance and signs and symptoms
• Focus Assessment: skin/extremities/ abdomen and sacrum area for edema
•Assess perfusion: edema may impair perfusion to extremities, assess peripheral and central
pulses, capillary refill, skin color, temp, sensory and motor function
•Observe for urine output
Lab values fluid overload - ANSWER✔️•Serum osmolality (275-295 mOsm/kg)
•Decrease found in overhydration <275; and < 265 is critical finding
•CBC
•Decrease hemoglobin and hematocrit
•BUN
•decreased BUN
•Electrolytes
•Decreased sodium (shifts due to dilution)
•Urine specific gravity Decrease < 1.005
fluid overload interventions/goal - ANSWER✔️•Goal: reduce excess body fluids, promote
desired elimination
•Manage underlying cause
•Restrict dietary sodium intake
•Monitor I/O
•Administer diuretic
•Monitor client's s/s and electrolytes values
•Restrict oral and other fluid intake as prescribed
Fluid overload complications - ANSWER✔️•Isotonic overhydration
•HF and pulmonary edema
•Seizure
•Coma
Fluid overload medications - ANSWER✔️Furosemide
Mannitol
S/S of dehydration - ANSWER✔️•Vital signs: hyperthermia, ST, thread pulse, hypotension,
decrease CVP
•Neuromusculoskeletal: Dizziness, syncope, confusion, weakness, fatigue
•GI: thirst, dry furrowed tongue, N/V, anorexia, weight loss
•Renal: Oliguria
•Other signs: Diminish capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flat neck
vein
,Dehydration assessment - ANSWER✔️•Assess for condition leading to dehydration: diarrhea,
poor intake, vigorous exercise, vomiting, polyuria, fluid losses (burns, trauma) clients with
drains/NG tube, burns/fluid shifts, overuse of diuretic
Dehydration labs - ANSWER✔️•Serum electrolytes (hypernatremia)
•Increased serum osmolality normal 275- 295 mOsm/kg; elevated > 295 found in dehydration; >
320 is critical finding
•CBC elevated H/H
•Elevated urine specific gravity > 1.030
•Increased BUN
Hyperkalemia ECG changes - ANSWER✔️peaked T waves, prolonged PR interval, ST
depression, loss of p waves, prolonged QRS
Hypokalemia ECG changes - ANSWER✔️•ST depression, flattened T wave, prolonged QRS,
PVCs
Hyperkalemia interventions - ANSWER✔️•Determine and manage underlying cause
•Decrease oral or IV intake of K+ (restrict diet)
•Potassium binding med
•IV infusion of insulin with glucose to force K+ into the cell and reduce serum K+
•IV infusion of calcium gluconate or sodium bicarbonate to decrease cellular cardiac excitability
•Dialysis
•Provide K+ restrict diet (avoid avocados, broccoli, dairy products, bananas)
hyperkalemia nutrition - ANSWER✔️•You should avoid organ meat, preserved meat, dairy
products, dried fruit, bananas, cantaloupe
•Vegetables: avocados, broccoli, dried bean or peas, potatoes, spinach
Hypokalemia interventions - ANSWER✔️•Oral and IV supplementations
Ensure adequate gas exchange
Safety for falls prevention
Monitor signs and symptoms
Monitor lab values
Potassium diet
Hyperkalemia complications - ANSWER✔️•V fib
•Complete respiratory arrest
•Cardiac standstill/arrest
Hypokalemia complications - ANSWER✔️•Lethal cardiac dysrhythmias
•Coma
•Cardiac arrest
Medications for Hyper/hypo kalemia - ANSWER✔️•Furosemide
, •Potassium chloride
Clinical Hints:
•Both hyper and hypo lead to cardiac irritability and dysrhythmias
•Monitor ECG closely and report to physician
Hypermagnesemia causes - ANSWER✔️•increase magnesium intake
•Antacid and laxative with magnesium containing
•Decrease kidney excretion of magnesium resulting in kidney disease
S/S of hypermagnesemia - ANSWER✔️•CV: Bradycardia, hypotension, respiratory depression
•CNS: drowsy, lethargic, coma if prolong
•GI; N/V
•Neuromuscular: absent deep tendon reflexes, voluntary skeletal muscle contractions, respiratory
muscle are weak
Hypermagnesemia interventions - ANSWER✔️•Determine and manage underlying cause
•Focus is on prevention
•Avoid mag containing foods (green vegetables, nuts, bananas, orange, peanut butter, chocolate)
•Emergency treatment: calcium gluconate or calcium chloride
•Promote urinary excretion with IV fluids, oral fluids, and IV furosemide
•Impair renal function use dialysis to draw off mag
Magnesium - ANSWER✔️1.5-2.5
Hypomagnesemia causes - ANSWER✔️•Malnutrition
•Starvation
•Diarrhea
•Crohns disease
•Drugs (diuretics, aminoglycoside AB)
•Ethanol ingestion
Hypomagnesemia S/S - ANSWER✔️•Hypertension, skeletal numbness and tingling, painful
muscle contraction
•Chvostek and Trousseau signs
•Decrease motility, anorexia, N, constipation, abdominal distention
Hypomagnesemia interventions - ANSWER✔️•Determine and manage underlying cause
•Dietary replacement of mag supplements/mag containing foods
•With significant deficits, provide IV mag
•Assess deep tendon reflexes when receiving magnesium IV infusion
Hypermagnesemia complications - ANSWER✔️•Paralysis
•Respiratory and cardiac arrest
MED-SURG NURSING | QUESTIONS AND
VERIFIED ANSWERS (A+ GUARANTEE)
Causes of fluid overload - ANSWER✔️•Excessive fluid replacement
•Kidney failure (late phase)
•Heart failure
•Long term corticosteroid therapy
•Syndrome of inappropriate antidiuretic hormone (SIADH)
•Psychiatric disorders with polydipsia
•Water intoxication
s/s fluid overload - ANSWER✔️•CV: tachycardia, bounding pulse, HTN, decrease pulse
pressure, JVD, weight gain
•Resp: increase and shallow resp; SOB, crackles lung sounds
•Skin: pitting edema, skin pale and cool to touch
•Neuromuscular: LOC, HA, visual disturbance, muscle weakness, paresthesia
•GI: increase motility, enlarge liver
,Assessment for fluid overload - ANSWER✔️•Assess risk r/t age and diagnosis, history
(overhydration, CHF, kidney disease)
•Assess vital signs why: watch for bounding tachycardia, HTN, dysrhythmias, tachypnea
•Assess lung sounds (crackles) , weight, LOC, Observe JVD
•Assess lab values: electrolytes imbalance and signs and symptoms
• Focus Assessment: skin/extremities/ abdomen and sacrum area for edema
•Assess perfusion: edema may impair perfusion to extremities, assess peripheral and central
pulses, capillary refill, skin color, temp, sensory and motor function
•Observe for urine output
Lab values fluid overload - ANSWER✔️•Serum osmolality (275-295 mOsm/kg)
•Decrease found in overhydration <275; and < 265 is critical finding
•CBC
•Decrease hemoglobin and hematocrit
•BUN
•decreased BUN
•Electrolytes
•Decreased sodium (shifts due to dilution)
•Urine specific gravity Decrease < 1.005
fluid overload interventions/goal - ANSWER✔️•Goal: reduce excess body fluids, promote
desired elimination
•Manage underlying cause
•Restrict dietary sodium intake
•Monitor I/O
•Administer diuretic
•Monitor client's s/s and electrolytes values
•Restrict oral and other fluid intake as prescribed
Fluid overload complications - ANSWER✔️•Isotonic overhydration
•HF and pulmonary edema
•Seizure
•Coma
Fluid overload medications - ANSWER✔️Furosemide
Mannitol
S/S of dehydration - ANSWER✔️•Vital signs: hyperthermia, ST, thread pulse, hypotension,
decrease CVP
•Neuromusculoskeletal: Dizziness, syncope, confusion, weakness, fatigue
•GI: thirst, dry furrowed tongue, N/V, anorexia, weight loss
•Renal: Oliguria
•Other signs: Diminish capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flat neck
vein
,Dehydration assessment - ANSWER✔️•Assess for condition leading to dehydration: diarrhea,
poor intake, vigorous exercise, vomiting, polyuria, fluid losses (burns, trauma) clients with
drains/NG tube, burns/fluid shifts, overuse of diuretic
Dehydration labs - ANSWER✔️•Serum electrolytes (hypernatremia)
•Increased serum osmolality normal 275- 295 mOsm/kg; elevated > 295 found in dehydration; >
320 is critical finding
•CBC elevated H/H
•Elevated urine specific gravity > 1.030
•Increased BUN
Hyperkalemia ECG changes - ANSWER✔️peaked T waves, prolonged PR interval, ST
depression, loss of p waves, prolonged QRS
Hypokalemia ECG changes - ANSWER✔️•ST depression, flattened T wave, prolonged QRS,
PVCs
Hyperkalemia interventions - ANSWER✔️•Determine and manage underlying cause
•Decrease oral or IV intake of K+ (restrict diet)
•Potassium binding med
•IV infusion of insulin with glucose to force K+ into the cell and reduce serum K+
•IV infusion of calcium gluconate or sodium bicarbonate to decrease cellular cardiac excitability
•Dialysis
•Provide K+ restrict diet (avoid avocados, broccoli, dairy products, bananas)
hyperkalemia nutrition - ANSWER✔️•You should avoid organ meat, preserved meat, dairy
products, dried fruit, bananas, cantaloupe
•Vegetables: avocados, broccoli, dried bean or peas, potatoes, spinach
Hypokalemia interventions - ANSWER✔️•Oral and IV supplementations
Ensure adequate gas exchange
Safety for falls prevention
Monitor signs and symptoms
Monitor lab values
Potassium diet
Hyperkalemia complications - ANSWER✔️•V fib
•Complete respiratory arrest
•Cardiac standstill/arrest
Hypokalemia complications - ANSWER✔️•Lethal cardiac dysrhythmias
•Coma
•Cardiac arrest
Medications for Hyper/hypo kalemia - ANSWER✔️•Furosemide
, •Potassium chloride
Clinical Hints:
•Both hyper and hypo lead to cardiac irritability and dysrhythmias
•Monitor ECG closely and report to physician
Hypermagnesemia causes - ANSWER✔️•increase magnesium intake
•Antacid and laxative with magnesium containing
•Decrease kidney excretion of magnesium resulting in kidney disease
S/S of hypermagnesemia - ANSWER✔️•CV: Bradycardia, hypotension, respiratory depression
•CNS: drowsy, lethargic, coma if prolong
•GI; N/V
•Neuromuscular: absent deep tendon reflexes, voluntary skeletal muscle contractions, respiratory
muscle are weak
Hypermagnesemia interventions - ANSWER✔️•Determine and manage underlying cause
•Focus is on prevention
•Avoid mag containing foods (green vegetables, nuts, bananas, orange, peanut butter, chocolate)
•Emergency treatment: calcium gluconate or calcium chloride
•Promote urinary excretion with IV fluids, oral fluids, and IV furosemide
•Impair renal function use dialysis to draw off mag
Magnesium - ANSWER✔️1.5-2.5
Hypomagnesemia causes - ANSWER✔️•Malnutrition
•Starvation
•Diarrhea
•Crohns disease
•Drugs (diuretics, aminoglycoside AB)
•Ethanol ingestion
Hypomagnesemia S/S - ANSWER✔️•Hypertension, skeletal numbness and tingling, painful
muscle contraction
•Chvostek and Trousseau signs
•Decrease motility, anorexia, N, constipation, abdominal distention
Hypomagnesemia interventions - ANSWER✔️•Determine and manage underlying cause
•Dietary replacement of mag supplements/mag containing foods
•With significant deficits, provide IV mag
•Assess deep tendon reflexes when receiving magnesium IV infusion
Hypermagnesemia complications - ANSWER✔️•Paralysis
•Respiratory and cardiac arrest
