Exam 1 NR 324 Adult Health 1
Questions with Verified Answers
What age group has the highest percentage of water content? - ANSWERSPreterm /
Neonates
Two fluid compartments in the body - ANSWERSIntracellular space (inside cells)
located in the ICF
Extracellular space (outside cells) located in the ECF
ICF makes up what percent of total body weight? - ANSWERS40%
What are the two main compartments containing ECF? What other compartments are
there? - ANSWERSInterstitial fluid (fluid in the spaces between cells)
Intravascular fluid (plasma)
Other compartments include lymph and transcellular fluids
Transcellular fluid includes - ANSWERSCerebrospinal fluid, fluid in the gastrointestinal
tract, and joint spaces as well as pleural, peritoneal, intraocular, and pericardial fluid.
1L of water = _____ lb. - ANSWERS2.2 lb (1kg)
The concentrations of electrolytes in body fluids is expressed in _________ -
ANSWERSmilliequivalents (mEq) per Liter
What are the main Ions found in the ECF and ICF - ANSWERSECF cation- sodium,
with small amounts of potassium, calcium, and magnesium
ECF anion- chloride, with small amounts of bicarbonate, sulfate, and phosphate anions.
ICF cation- potassium, with small amounts of magnesium and sodium
ICF anion- phosphate, with some protein and a small amount of bicarbonate.
Hypovolemia (ECF volume deficit) - ANSWERSabnormal loss of normal body fluids,
(D/V, hemorrhage, polyuria) inadequate intake, or plasma-to-interstitial fluid shift
Fluid volume deficit
Assessment- Causes-Treatment-Client education - ANSWERSAssessment-
Restlessness, drowsiness, lethargy, confusion
• Thirst, dry mucous membranes
• Cold clammy skin
• Decreased skin turgor, ↓ capillary refill
• Postural hypotension, ↑ pulse, ↓ CVP
• ↓ Urine output, concentrated urine
• ↑ Respiratory rate
,• Weakness, dizziness
• Weight loss
• Seizures, coma
Causes- • ↑ Insensible water loss or perspiration (high fever, heatstroke)
• Diabetes insipidus
• Osmotic diuresis
• Hemorrhage
• GI losses: vomiting, NG suction, diarrhea, fistula drainage
• Overuse of diuretics
• Inadequate fluid intake
• Third-space fluid shifts: burns, pancreatitis
Treatment- replace water and electrolytes with balanced IV solutions
Client education- Good skin care, if orthostatic hypotension is present, teach to change
positions slowly, remind patient to drink
Hypervolemia (ECF volume excess) - ANSWERSExcessive intake of fluids, abnormal
retention of fluids (HF or renal failure), or interstitial-to-plasma fluid shift
Fluid volume excess
Assessment- Causes-Treatment-Client education - ANSWERSAssessment- •
Headache, confusion, lethargy
• Peripheral edema
• Jugular venous distention
• S3 heart sound
• Bounding pulse, ↑ BP, ↑ CVP
• Polyuria (with normal renal function)
• Dyspnea, crackles, pulmonary edema
• Muscle spasms
• Weight gain
• Seizures, coma
Causes- • Excessive isotonic or hypotonic IV fluids
• Heart failure
• Renal failure
• Primary polydipsia
• SIADH
• Cushing syndrome
• Long-term use of corticosteroids
Treatment-Remove fluid without changing electrolyte composition or osmolality of ECF
Client education- elevate edematous extremities
Nutrition related to potassium - ANSWERSDiet is the source
-Fruit, dried fruits and vegetables
-Many salt substitutes contain substantial K+
Nutrition related to sodium - ANSWERS-Daily intake far exceeds bodys daily
requirments
,-Glucose promotes sodium and water absorption
Hypertonic solutions - ANSWERSinitially raises the osmolality of ECF and expands it
-higher osmotic pressure draws water out of the cells into the ECF
-Useful in treatment of hyponatremia and trauma patients with head injuries
Isotonic solutions - ANSWERShas a similar concentration of water and electrolytes to
plasma, with an osmolality of 250 to 375 mOsm/L
-administering an isotonic solution expands only ECF and the fluid does not move into
cells
-the ideal fluid replacement for patients with ECF volume deficits
Hypotonic solutions - ANSWERSsolution has more water than electrolytes, with an
osmolality of less than 250 mOsm/kg.
-Infusing a hypotonic solution dilutes ECf
-good for treating patients with hypernatremia
As a nurse it is important to remember what administration guidelines when
administering IV KCL? - ANSWERS• IV KCl must always be diluted and never given in
concentrated amounts.
• Never give KCl via IV push or as a bolus.
• Invert IV bags containing KCl several times to ensure even distribution in the bag.
• Do not add KCl to a hanging IV bag to prevent giving a bolus dose.
Hypernatremia - ANSWERSOccurs when either too much water is lost or not enough
water intake, or too much salt is taken in
What S/S should the nurse look for when a patient is experiencing hypernatremia with
decreased, normal and increased ECF volume? - ANSWERSHypernatremia with
decreased ECF volume: • Restlessness, agitation, lethargy, seizures, coma
• Intense thirst, dry swollen tongue, sticky mucous membranes
• Postural hypotension, ↓ CVP, weight loss, ↑ pulse
• Weakness, muscle cramps
Hypernatremia with normal or increased ECF volume: • Restlessness, agitation,
twitching, seizures, coma
• Intense thirst, flushed skin
• Weight gain, peripheral and pulmonary edema, ↑ BP, ↑ CVP
Sodium plays a key role in the body by... - ANSWERSTransmitting nerve impulses
Hyponatremia - ANSWERSOccurs when the body loses more sodium than water and
there is a low level of sodium in the blood or when too much water is taken in or
retained or when there is organ failure
Hyperkalemia - ANSWERSOccurs when potassium levels in your blood are higher than
normal
, -Excess K+ intake
-Shift of K+ out of cells
-Failure to eliminate K+
Potassium is crucial for __________ and ____________ function within the body? -
ANSWERSNeuromuscular and cardiac function
What S/S should the nurse look for when a patient is experiencing hyperkalemia? -
ANSWERS• Fatigue, irritability
• Muscle weakness, cramps
• Loss of muscle tone
• Paresthesias, decreased reflexes
• Abdominal cramping, diarrhea, vomiting
• Confusion
• Irregular pulse
• Tetany
What S/S should the nurse look for when a patient is experiencing hyponatremia with
decreased, normal and increased ECF volume? - ANSWERSHyponatremia with
decreased ECF volume: • Irritability, apprehension, confusion, dizziness, personality
changes, tremors, seizures, coma
• Dry mucous membranes
• Postural hypotension, ↓ CVP, ↓ jugular venous filling, ↑ pulse, thready pulse
• Cold and clammy skin
Hyponatremia with normal or increased ECF volume: • Headache, apathy, confusion,
muscle spasms, seizures, coma
• Nausea, vomiting, diarrhea, abdominal cramps
• Weight gain, ↑ BP, ↑ CVP
Hypokalemia - ANSWERSOccurs when potassium levels in your blood are lower than
normal
-K+ loss
-Shift of K+ into cells
-Lack of K+ intake
What S/S should the nurse look for when a patient is experiencing hypokalemia? -
ANSWERS• Fatigue
• Muscle weakness, leg cramps
• Soft, flabby muscles
• Paresthesias, decreased reflexes
• Constipation, nausea, paralytic ileus
• Shallow respirations
• Weak, irregular pulse
• Hyperglycemia
Questions with Verified Answers
What age group has the highest percentage of water content? - ANSWERSPreterm /
Neonates
Two fluid compartments in the body - ANSWERSIntracellular space (inside cells)
located in the ICF
Extracellular space (outside cells) located in the ECF
ICF makes up what percent of total body weight? - ANSWERS40%
What are the two main compartments containing ECF? What other compartments are
there? - ANSWERSInterstitial fluid (fluid in the spaces between cells)
Intravascular fluid (plasma)
Other compartments include lymph and transcellular fluids
Transcellular fluid includes - ANSWERSCerebrospinal fluid, fluid in the gastrointestinal
tract, and joint spaces as well as pleural, peritoneal, intraocular, and pericardial fluid.
1L of water = _____ lb. - ANSWERS2.2 lb (1kg)
The concentrations of electrolytes in body fluids is expressed in _________ -
ANSWERSmilliequivalents (mEq) per Liter
What are the main Ions found in the ECF and ICF - ANSWERSECF cation- sodium,
with small amounts of potassium, calcium, and magnesium
ECF anion- chloride, with small amounts of bicarbonate, sulfate, and phosphate anions.
ICF cation- potassium, with small amounts of magnesium and sodium
ICF anion- phosphate, with some protein and a small amount of bicarbonate.
Hypovolemia (ECF volume deficit) - ANSWERSabnormal loss of normal body fluids,
(D/V, hemorrhage, polyuria) inadequate intake, or plasma-to-interstitial fluid shift
Fluid volume deficit
Assessment- Causes-Treatment-Client education - ANSWERSAssessment-
Restlessness, drowsiness, lethargy, confusion
• Thirst, dry mucous membranes
• Cold clammy skin
• Decreased skin turgor, ↓ capillary refill
• Postural hypotension, ↑ pulse, ↓ CVP
• ↓ Urine output, concentrated urine
• ↑ Respiratory rate
,• Weakness, dizziness
• Weight loss
• Seizures, coma
Causes- • ↑ Insensible water loss or perspiration (high fever, heatstroke)
• Diabetes insipidus
• Osmotic diuresis
• Hemorrhage
• GI losses: vomiting, NG suction, diarrhea, fistula drainage
• Overuse of diuretics
• Inadequate fluid intake
• Third-space fluid shifts: burns, pancreatitis
Treatment- replace water and electrolytes with balanced IV solutions
Client education- Good skin care, if orthostatic hypotension is present, teach to change
positions slowly, remind patient to drink
Hypervolemia (ECF volume excess) - ANSWERSExcessive intake of fluids, abnormal
retention of fluids (HF or renal failure), or interstitial-to-plasma fluid shift
Fluid volume excess
Assessment- Causes-Treatment-Client education - ANSWERSAssessment- •
Headache, confusion, lethargy
• Peripheral edema
• Jugular venous distention
• S3 heart sound
• Bounding pulse, ↑ BP, ↑ CVP
• Polyuria (with normal renal function)
• Dyspnea, crackles, pulmonary edema
• Muscle spasms
• Weight gain
• Seizures, coma
Causes- • Excessive isotonic or hypotonic IV fluids
• Heart failure
• Renal failure
• Primary polydipsia
• SIADH
• Cushing syndrome
• Long-term use of corticosteroids
Treatment-Remove fluid without changing electrolyte composition or osmolality of ECF
Client education- elevate edematous extremities
Nutrition related to potassium - ANSWERSDiet is the source
-Fruit, dried fruits and vegetables
-Many salt substitutes contain substantial K+
Nutrition related to sodium - ANSWERS-Daily intake far exceeds bodys daily
requirments
,-Glucose promotes sodium and water absorption
Hypertonic solutions - ANSWERSinitially raises the osmolality of ECF and expands it
-higher osmotic pressure draws water out of the cells into the ECF
-Useful in treatment of hyponatremia and trauma patients with head injuries
Isotonic solutions - ANSWERShas a similar concentration of water and electrolytes to
plasma, with an osmolality of 250 to 375 mOsm/L
-administering an isotonic solution expands only ECF and the fluid does not move into
cells
-the ideal fluid replacement for patients with ECF volume deficits
Hypotonic solutions - ANSWERSsolution has more water than electrolytes, with an
osmolality of less than 250 mOsm/kg.
-Infusing a hypotonic solution dilutes ECf
-good for treating patients with hypernatremia
As a nurse it is important to remember what administration guidelines when
administering IV KCL? - ANSWERS• IV KCl must always be diluted and never given in
concentrated amounts.
• Never give KCl via IV push or as a bolus.
• Invert IV bags containing KCl several times to ensure even distribution in the bag.
• Do not add KCl to a hanging IV bag to prevent giving a bolus dose.
Hypernatremia - ANSWERSOccurs when either too much water is lost or not enough
water intake, or too much salt is taken in
What S/S should the nurse look for when a patient is experiencing hypernatremia with
decreased, normal and increased ECF volume? - ANSWERSHypernatremia with
decreased ECF volume: • Restlessness, agitation, lethargy, seizures, coma
• Intense thirst, dry swollen tongue, sticky mucous membranes
• Postural hypotension, ↓ CVP, weight loss, ↑ pulse
• Weakness, muscle cramps
Hypernatremia with normal or increased ECF volume: • Restlessness, agitation,
twitching, seizures, coma
• Intense thirst, flushed skin
• Weight gain, peripheral and pulmonary edema, ↑ BP, ↑ CVP
Sodium plays a key role in the body by... - ANSWERSTransmitting nerve impulses
Hyponatremia - ANSWERSOccurs when the body loses more sodium than water and
there is a low level of sodium in the blood or when too much water is taken in or
retained or when there is organ failure
Hyperkalemia - ANSWERSOccurs when potassium levels in your blood are higher than
normal
, -Excess K+ intake
-Shift of K+ out of cells
-Failure to eliminate K+
Potassium is crucial for __________ and ____________ function within the body? -
ANSWERSNeuromuscular and cardiac function
What S/S should the nurse look for when a patient is experiencing hyperkalemia? -
ANSWERS• Fatigue, irritability
• Muscle weakness, cramps
• Loss of muscle tone
• Paresthesias, decreased reflexes
• Abdominal cramping, diarrhea, vomiting
• Confusion
• Irregular pulse
• Tetany
What S/S should the nurse look for when a patient is experiencing hyponatremia with
decreased, normal and increased ECF volume? - ANSWERSHyponatremia with
decreased ECF volume: • Irritability, apprehension, confusion, dizziness, personality
changes, tremors, seizures, coma
• Dry mucous membranes
• Postural hypotension, ↓ CVP, ↓ jugular venous filling, ↑ pulse, thready pulse
• Cold and clammy skin
Hyponatremia with normal or increased ECF volume: • Headache, apathy, confusion,
muscle spasms, seizures, coma
• Nausea, vomiting, diarrhea, abdominal cramps
• Weight gain, ↑ BP, ↑ CVP
Hypokalemia - ANSWERSOccurs when potassium levels in your blood are lower than
normal
-K+ loss
-Shift of K+ into cells
-Lack of K+ intake
What S/S should the nurse look for when a patient is experiencing hypokalemia? -
ANSWERS• Fatigue
• Muscle weakness, leg cramps
• Soft, flabby muscles
• Paresthesias, decreased reflexes
• Constipation, nausea, paralytic ileus
• Shallow respirations
• Weak, irregular pulse
• Hyperglycemia
