NUR 330 exam 1 UPDATED ACTUAL Questions and CORRECT
Answers
Hypovolemia fluid volume deficit
loss of extracellular fluid exceeds intake ratio of water
causes of FVD •Abnormal fluid losses
• Vomiting, diarrhea, sweating, GI suctioning
• Decreased intake
• Nausea, lack of access to fluids
• Third-space fluid shifts
• Due to burns, ascites
• Additional causes
• Diabetes insipidus, adrenal insufficiency, hemorrhage
clinical manifestations of FVD -weight loss
-decreased skin turgor
-hypotension
-tachycardia
-urine output
-increased BUN and creatinine
-electrolyte imbalances
nursing management of FVD -daily weights
-I&O at least every 8 hours
-vital signs
-skin assessments+ full assessment of mucosa
-administration of oral fluid
-administration and monitoring of parental fluids
-neurologic function
Hypervolemia fluid volume excess
due to fluid overload in the total body sodium content
causes of FVE -Due to fluid overload or diminished homeostatic mechanisms
-Heart failure, kidney injury, cirrhosis of liver
-Contributing factors: Consumption of excessive amounts of table salt or other
sodium salts
-Excessive administration of sodium-containing fluids
clinical manifestations of FVE -weight gain
-edema
-distended neck veins
-crackles in lungs
-HTN, bounding pulse
-decreased HGB, HCT
, nursing management of FVE -I&O and daily weight
-promote adherence to fluid restriction, patient teaching related to sodium and
fluid restriction
-monitor, avoid sources of excessive sodium, including medications
-promote rest
medication for FVE -diuretics: furosemide, HCTZ, spironolactone
-parental fluids
-dialysis in severe cases
sodium 136-145 mEq/L
Hyponatremia less than 136 mEq/L
causes of hyponatremia -GI fluid loss
-excessive diaphoresis
-diuretics
-burns
-hyperglycemia
-excessive injection of water
-kidney and heart failure
-hypotonic solution
-hyperglycemia
interventions for hyponatremia -treat underlying conditions
-sodium replacement
-water restrictions (diuretics, fluid restriction)
-sodium containing foods
Priority: monitor for response to therapy and prevent hypernatremia
Hypernatremia greater than 145 mEq/L
causes of hypernatremia -hyperaldosteronism
-kidney failure
-corticosteroids
-Cushing syndrome
-excessive intake or IVF with sodium
-steroids
-dehydration
-fever
-hyperventilation
-infection
-excessive diaphoresis
-diarrhea
interventions of hypernatremia -gradual lowering of serum sodium levels (prevents cerebral edema)
-IV fluids for fluid loss (NS or D5%, 0.45%)
-not fluid loss: D5W, diuretics
-sodium restriction
-continue assessment
potassium 3.5-5 mEq/L
Answers
Hypovolemia fluid volume deficit
loss of extracellular fluid exceeds intake ratio of water
causes of FVD •Abnormal fluid losses
• Vomiting, diarrhea, sweating, GI suctioning
• Decreased intake
• Nausea, lack of access to fluids
• Third-space fluid shifts
• Due to burns, ascites
• Additional causes
• Diabetes insipidus, adrenal insufficiency, hemorrhage
clinical manifestations of FVD -weight loss
-decreased skin turgor
-hypotension
-tachycardia
-urine output
-increased BUN and creatinine
-electrolyte imbalances
nursing management of FVD -daily weights
-I&O at least every 8 hours
-vital signs
-skin assessments+ full assessment of mucosa
-administration of oral fluid
-administration and monitoring of parental fluids
-neurologic function
Hypervolemia fluid volume excess
due to fluid overload in the total body sodium content
causes of FVE -Due to fluid overload or diminished homeostatic mechanisms
-Heart failure, kidney injury, cirrhosis of liver
-Contributing factors: Consumption of excessive amounts of table salt or other
sodium salts
-Excessive administration of sodium-containing fluids
clinical manifestations of FVE -weight gain
-edema
-distended neck veins
-crackles in lungs
-HTN, bounding pulse
-decreased HGB, HCT
, nursing management of FVE -I&O and daily weight
-promote adherence to fluid restriction, patient teaching related to sodium and
fluid restriction
-monitor, avoid sources of excessive sodium, including medications
-promote rest
medication for FVE -diuretics: furosemide, HCTZ, spironolactone
-parental fluids
-dialysis in severe cases
sodium 136-145 mEq/L
Hyponatremia less than 136 mEq/L
causes of hyponatremia -GI fluid loss
-excessive diaphoresis
-diuretics
-burns
-hyperglycemia
-excessive injection of water
-kidney and heart failure
-hypotonic solution
-hyperglycemia
interventions for hyponatremia -treat underlying conditions
-sodium replacement
-water restrictions (diuretics, fluid restriction)
-sodium containing foods
Priority: monitor for response to therapy and prevent hypernatremia
Hypernatremia greater than 145 mEq/L
causes of hypernatremia -hyperaldosteronism
-kidney failure
-corticosteroids
-Cushing syndrome
-excessive intake or IVF with sodium
-steroids
-dehydration
-fever
-hyperventilation
-infection
-excessive diaphoresis
-diarrhea
interventions of hypernatremia -gradual lowering of serum sodium levels (prevents cerebral edema)
-IV fluids for fluid loss (NS or D5%, 0.45%)
-not fluid loss: D5W, diuretics
-sodium restriction
-continue assessment
potassium 3.5-5 mEq/L
