NSG 170 Fluids and Electrolytes || with 100% Correct Answers.
What changes in vitals could indicate a patient has extracellular fluid volume (ECV) EXCESS?
correct answers - Decrease in BP or orthostatic hypotension caused by decreased stroke volume.
- Baroreceptor response causes rapid, thready pulse.
- Fullness of neck veins (normally neck veins are full when person is supine and flat when
person is upright or semi-upright)
- Auscultation of lungs with crackles or rhonchi in dependent lobes of lungs may signal fluid
buildup.
What changes in vitals could indicate a patient is extracellular fluid volume (ECV) DEFICIT?
correct answers - Sluggish capillary refill is an indirect measure of poor tissue perfusion
- Reduced urine production (Ave daily adult urine output is 1500mL; OLIGURIA is urine output
that is less than 400 mL/24hr.)
- Concentration of the urine (indicated by dark yellow color.)
- Thirst (Occurs with hypernatremia and severe ECV)
What would a clinical marker of vascular volume be? correct answers The assessment of signs
and symptoms and interpret them accurately (Infusion of Na+- containing IV fluid expands
extracellular fluid volume (ECV)(vascular and interstitial).
What does TKO stand for? correct answers to keep open
,What does KVO stand for? correct answers keep vein open
What does EID stand for? correct answers electronic infusion device
insensible water loss correct answers Normal daily insensible fluid loss is 600 - 900 per day
(sweat, stool, etc.)
Infiltration correct answers Occurs when an IV catheter becomes dislodged or a vein ruptures
and IV fluid inadvertently enter subcutaneous tissue around the venipuncture site.
*Causes coolness, paleness, and swelling of the area
Infiltration:
0 no symptoms
2 skin blanched edema
3 skin blanched translucent gross edema
4 skin blanched translucent skin tight, leaking
phlebitis correct answers Inflammation of inner layer of a vein as a result of chemical,
mechanical, or bacterial causes.
Symptoms: Pain, tenderness, redness
Extravasation correct answers When the IV fluid contains additives that damage tissue.
,*Causes Pain, redness, burning, no blood return, and swelling of the area
Circulatory overload of IV solution correct answers IV solution infused too rapidly or in too
great an amount.
What assessment findings are present with extracellular fluid volume (ECV) excess with NA+
correct answers - Crackles in dependent parts of the lungs
- SOB
- Dependent edema
TREATMENT
- Reduce IV flow rate and notify patients health care provider
- Monitor vital signs and laboratory reports of serum levels
- Raise head of the bed
- Administer oxygen and diuretic if ordered
What assessment findings are present with HYPOnatremia with hypotonic fluid? correct answers
- Confusion
- Seizures
, TREATMENT
- Reduce IV flow rate and notify patients health care provider
- Monitor vital signs and laboratory reports of serum levels
What assessment findings are present with HYPERnatremia with NA+ containing hypertonic
fluid? correct answers - Confusion
- Seizures
TREATMENT
- Reduce IV flow rate and notify patients health care provider
- Monitor vital signs and laboratory reports of serum levels
What assessment findings are present with HYPERkalemia from K+ containing fluid? correct
answers - Cardiac dysrhythmias
- Muscle weakness
- Abdominal distention
How often do you assess a vascular access devise (VAD) site? correct answers - At least every 4
hours (on oriented adult)
- At least every 1 to 2 hours for critically ill patients and patients receiving sedatives
What changes in vitals could indicate a patient has extracellular fluid volume (ECV) EXCESS?
correct answers - Decrease in BP or orthostatic hypotension caused by decreased stroke volume.
- Baroreceptor response causes rapid, thready pulse.
- Fullness of neck veins (normally neck veins are full when person is supine and flat when
person is upright or semi-upright)
- Auscultation of lungs with crackles or rhonchi in dependent lobes of lungs may signal fluid
buildup.
What changes in vitals could indicate a patient is extracellular fluid volume (ECV) DEFICIT?
correct answers - Sluggish capillary refill is an indirect measure of poor tissue perfusion
- Reduced urine production (Ave daily adult urine output is 1500mL; OLIGURIA is urine output
that is less than 400 mL/24hr.)
- Concentration of the urine (indicated by dark yellow color.)
- Thirst (Occurs with hypernatremia and severe ECV)
What would a clinical marker of vascular volume be? correct answers The assessment of signs
and symptoms and interpret them accurately (Infusion of Na+- containing IV fluid expands
extracellular fluid volume (ECV)(vascular and interstitial).
What does TKO stand for? correct answers to keep open
,What does KVO stand for? correct answers keep vein open
What does EID stand for? correct answers electronic infusion device
insensible water loss correct answers Normal daily insensible fluid loss is 600 - 900 per day
(sweat, stool, etc.)
Infiltration correct answers Occurs when an IV catheter becomes dislodged or a vein ruptures
and IV fluid inadvertently enter subcutaneous tissue around the venipuncture site.
*Causes coolness, paleness, and swelling of the area
Infiltration:
0 no symptoms
2 skin blanched edema
3 skin blanched translucent gross edema
4 skin blanched translucent skin tight, leaking
phlebitis correct answers Inflammation of inner layer of a vein as a result of chemical,
mechanical, or bacterial causes.
Symptoms: Pain, tenderness, redness
Extravasation correct answers When the IV fluid contains additives that damage tissue.
,*Causes Pain, redness, burning, no blood return, and swelling of the area
Circulatory overload of IV solution correct answers IV solution infused too rapidly or in too
great an amount.
What assessment findings are present with extracellular fluid volume (ECV) excess with NA+
correct answers - Crackles in dependent parts of the lungs
- SOB
- Dependent edema
TREATMENT
- Reduce IV flow rate and notify patients health care provider
- Monitor vital signs and laboratory reports of serum levels
- Raise head of the bed
- Administer oxygen and diuretic if ordered
What assessment findings are present with HYPOnatremia with hypotonic fluid? correct answers
- Confusion
- Seizures
, TREATMENT
- Reduce IV flow rate and notify patients health care provider
- Monitor vital signs and laboratory reports of serum levels
What assessment findings are present with HYPERnatremia with NA+ containing hypertonic
fluid? correct answers - Confusion
- Seizures
TREATMENT
- Reduce IV flow rate and notify patients health care provider
- Monitor vital signs and laboratory reports of serum levels
What assessment findings are present with HYPERkalemia from K+ containing fluid? correct
answers - Cardiac dysrhythmias
- Muscle weakness
- Abdominal distention
How often do you assess a vascular access devise (VAD) site? correct answers - At least every 4
hours (on oriented adult)
- At least every 1 to 2 hours for critically ill patients and patients receiving sedatives
