Adult Health 2 Exam #1
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1. Hyperkalemia causes • Impaired renal excretion—most common cause
• Shift from ICF to ECF
• Massive intake of K+
2. Hyperkalemia symptoms • Cramping leg pain
• Weak or paralyzed skeletal muscles
• Abdominal cramping or diarrhea
• Cardiac dysrhythmias/V-Fib (lethal) & notable
peaked "T" wave on EKG strip
3. Hypernatremia causes • Water loss or sodium gain
• Hyperosmolality
• Primary protection is thirst
•Fluid deficit
•Diet—excess Na intake
•Hypertonic NS IV fluid excess—3% (only give with
severe hyponatremia)
•Excessive isotonic NS IV fluid
•Hypertonic tube feedings with no water supplements
4. Treatment for hypernatremia • Diuretics (depending on the cause)
• IV Fluids (D5W or ½ NS)
• Restrict Na in diet
5. Symptoms of hypernatremia • Restlessness
• Agitation
• Seizures
• Coma
• Twitching
• Intense thirst
• Flushed skin
• Increased weight
, Adult Health 2 Exam #1
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• Edema (peripheral & pulmonary)
• HTN
• Increased Central Venous Pressure
6. Nursing Management/Treatment • Eliminate oral and parenteral K+ intake
for Hyperkalemia: • Increase elimination of K+ (many diuretics)—loop
diuretics are K+ wasting
• Administer K-Exalate medication—K+ will be excret-
ed in feces
• Force K+ from ECF to ICF
• IV insulin & glucose—pushes K+ back into cell
• IV Calcium Gluconate
• Monitor vitals/heart rhythm
7. Causes of volume imbalances vomiting, NG suctioning, diarrhea, diaphoresis, di-
uretics, diabetes insipidus, renal disease, adrenal in-
sufficiency, osmotic diuresis, peritonitis, intestinal ob-
struction, ascites, burns, hemorrhage, altered oral in-
take.
8. Risk factors for fluid loss strenuous exercising, increased intake of caffeine/al-
cohol, living at high elevations or in dry climates. older
adults due to loss of skin elasticity, loss of muscle
mass, diminished thirst reflex.
9. Hypovolemia findings dizziness, syncope, confusion, weakness/fatigue, olig-
uria (decreased production/concentration of urine),
, Adult Health 2 Exam #1
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diminished capillary refill, cool/clammy skin, di-
aphoresis, sunken eyes, flattened neck veins, poor
skin turgor/tenting, weight loss, low central venous
pressure.
10. Nursing care for hypovolemia monitor I & O, vitals, orthostatic BPs. watch for men-
tal status changes, give IV fluids as ordered, monitor
weight every 8 hours while fluid replacement is in
progress. Assess gait stability, initiate fall precautions.
Encourage pt to change positions slowly d/t hypoten-
sion potential.
11. hypovolemic shock occurs with significant loss of body fluids
12. Hypervolemia findings tachycardia, bounding pulse, HTN, tachypnea, in-
creased central venous pressure. weakness, HA, al-
tered LOC. ascites, crackles in lungs, cough, increased
respiratory rate, dyspnea. peripheral edema, weight
gain, distended neck veins, increased urine output.
13. Nursing care for hypervolemia monitor I & O, daily weight, assess breath sounds,
monitor peripheral edema, Na restricted diet as or-
dered, encourage rest, monitor diuretic use if or-
dered. monitor skin status d/t edema, monitor sodium
& potassium levels.
14. pulmonary edema
, Adult Health 2 Exam #1
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accumulation of fluid in the lungs. can be caused by
severe fluid overload.
15. symptoms of pulmonary edema Dyspnea, Cyanosis, tachypnea, tachycardia, pink
frothy sputum, restlessness, wheezing, crackles, de-
creased urine output, sudden weight gain.
16. A nurse is admitting a client who decreased skin turgor, concentrated urine, low-grade
reports nausea, vomiting, & weak- fever, tachypnea
ness. The client has dry oral mucous
membranes. Which of the following
findings should the nurse identify
as manifestations of fluid volume
deficit? (select all that apply)
17. A nurse is admitting an older adult dyspnea, edema, HTN, weakness
client who is experiencing dyspnea,
weakness, weight gain of 2 lb, and
1+ bilateral edema of the lower ex-
tremities. The client has a temper-
ature of 99 F, HR 96, R 26, O2 sat
94% on 3L O2 via NC, BP 152/96.
Which of the following manifesta-
tions of fluid volume excess should
the nurse expect? (select all that ap-
ply)
18. A nurse is assessing a client who is tachycardia
dehydrated for fluid volume deficit.
Which of the following findings
should the nurse expect in the
client?
Study online at https://quizlet.com/_72g72e
1. Hyperkalemia causes • Impaired renal excretion—most common cause
• Shift from ICF to ECF
• Massive intake of K+
2. Hyperkalemia symptoms • Cramping leg pain
• Weak or paralyzed skeletal muscles
• Abdominal cramping or diarrhea
• Cardiac dysrhythmias/V-Fib (lethal) & notable
peaked "T" wave on EKG strip
3. Hypernatremia causes • Water loss or sodium gain
• Hyperosmolality
• Primary protection is thirst
•Fluid deficit
•Diet—excess Na intake
•Hypertonic NS IV fluid excess—3% (only give with
severe hyponatremia)
•Excessive isotonic NS IV fluid
•Hypertonic tube feedings with no water supplements
4. Treatment for hypernatremia • Diuretics (depending on the cause)
• IV Fluids (D5W or ½ NS)
• Restrict Na in diet
5. Symptoms of hypernatremia • Restlessness
• Agitation
• Seizures
• Coma
• Twitching
• Intense thirst
• Flushed skin
• Increased weight
, Adult Health 2 Exam #1
Study online at https://quizlet.com/_72g72e
• Edema (peripheral & pulmonary)
• HTN
• Increased Central Venous Pressure
6. Nursing Management/Treatment • Eliminate oral and parenteral K+ intake
for Hyperkalemia: • Increase elimination of K+ (many diuretics)—loop
diuretics are K+ wasting
• Administer K-Exalate medication—K+ will be excret-
ed in feces
• Force K+ from ECF to ICF
• IV insulin & glucose—pushes K+ back into cell
• IV Calcium Gluconate
• Monitor vitals/heart rhythm
7. Causes of volume imbalances vomiting, NG suctioning, diarrhea, diaphoresis, di-
uretics, diabetes insipidus, renal disease, adrenal in-
sufficiency, osmotic diuresis, peritonitis, intestinal ob-
struction, ascites, burns, hemorrhage, altered oral in-
take.
8. Risk factors for fluid loss strenuous exercising, increased intake of caffeine/al-
cohol, living at high elevations or in dry climates. older
adults due to loss of skin elasticity, loss of muscle
mass, diminished thirst reflex.
9. Hypovolemia findings dizziness, syncope, confusion, weakness/fatigue, olig-
uria (decreased production/concentration of urine),
, Adult Health 2 Exam #1
Study online at https://quizlet.com/_72g72e
diminished capillary refill, cool/clammy skin, di-
aphoresis, sunken eyes, flattened neck veins, poor
skin turgor/tenting, weight loss, low central venous
pressure.
10. Nursing care for hypovolemia monitor I & O, vitals, orthostatic BPs. watch for men-
tal status changes, give IV fluids as ordered, monitor
weight every 8 hours while fluid replacement is in
progress. Assess gait stability, initiate fall precautions.
Encourage pt to change positions slowly d/t hypoten-
sion potential.
11. hypovolemic shock occurs with significant loss of body fluids
12. Hypervolemia findings tachycardia, bounding pulse, HTN, tachypnea, in-
creased central venous pressure. weakness, HA, al-
tered LOC. ascites, crackles in lungs, cough, increased
respiratory rate, dyspnea. peripheral edema, weight
gain, distended neck veins, increased urine output.
13. Nursing care for hypervolemia monitor I & O, daily weight, assess breath sounds,
monitor peripheral edema, Na restricted diet as or-
dered, encourage rest, monitor diuretic use if or-
dered. monitor skin status d/t edema, monitor sodium
& potassium levels.
14. pulmonary edema
, Adult Health 2 Exam #1
Study online at https://quizlet.com/_72g72e
accumulation of fluid in the lungs. can be caused by
severe fluid overload.
15. symptoms of pulmonary edema Dyspnea, Cyanosis, tachypnea, tachycardia, pink
frothy sputum, restlessness, wheezing, crackles, de-
creased urine output, sudden weight gain.
16. A nurse is admitting a client who decreased skin turgor, concentrated urine, low-grade
reports nausea, vomiting, & weak- fever, tachypnea
ness. The client has dry oral mucous
membranes. Which of the following
findings should the nurse identify
as manifestations of fluid volume
deficit? (select all that apply)
17. A nurse is admitting an older adult dyspnea, edema, HTN, weakness
client who is experiencing dyspnea,
weakness, weight gain of 2 lb, and
1+ bilateral edema of the lower ex-
tremities. The client has a temper-
ature of 99 F, HR 96, R 26, O2 sat
94% on 3L O2 via NC, BP 152/96.
Which of the following manifesta-
tions of fluid volume excess should
the nurse expect? (select all that ap-
ply)
18. A nurse is assessing a client who is tachycardia
dehydrated for fluid volume deficit.
Which of the following findings
should the nurse expect in the
client?
