NUR 242 — Exam 2 Comprehensive Study Guide
Ch 13–14 Fluids/Electrolytes/Acid-Base | Ch 27–30 Cardiovascular | Ch 57–59, 61, 64 Urinary/Renal/BPH
SECTION 1 — FLUIDS, ELECTROLYTES & ACID-BASE (Ch 13–14)
■ Normal Lab Values to Memorize
Na+ (Sodium) 135-145 K+ (Potassium) 3.5-5.0
Hyponatremia <135: GI loss, diuretics, burns, kidney disease Hypokalemia <3.5: diuretics, D/V, corticosteroids, insulin, albuterol
• S&S;: confusion, seizures, muscle twitching, N/D, weak/bounding pulse • S&S;: muscle weakness, irregular HR, ST depression, constipation
• Tx: 0.9% NS (mild); 3% saline (severe — monitor closely) • ECG: flattened T wave, U wave
• SAFETY: Correct slowly — max 12 mEq/L/24hr or risk osmotic • IV K+: NEVER push — always dilute, max 10 mEq/hr peripheral,
demyelination ensure UO >30 mL/hr first
Hypernatremia >145: dehydration, Cushing syndrome, fever Hyperkalemia >5.0: kidney failure, ACEi/ARBs, acidosis, crush injury,
• S&S;: agitation, confusion, muscle twitching, craves water potassium-sparing diuretics
• Tx: 0.45% NS or D5W (hypotonic), oral fluids, diuretics, Na restriction • S&S;: peaked T waves, bradycardia, dysrhythmia, diarrhea, paresthesia
• Tx: STOP K+ sources; glucose + insulin (shift K+ into cells); calcium
gluconate (cardiac protection FIRST); kayexalate
Ca2+ (Calcium) 8.5-10.5 Mg2+ (Magnesium) 1.8-2.6
Hypocalcemia: inadequate intake, diarrhea, alkalosis, diuretics, Hypomagnesemia: malnutrition, alcohol use, diarrhea, PPIs, diuretics
immobility • S&S;: hyperactive DTRs, Chvostek/Trousseau signs, tetany,
• S&S;: Chvostek sign (facial twitch), Trousseau sign (carpal spasm), dysrhythmia, HTN
tingling/paresthesia, tetany, osteoporosis • Often coexists with hypocalcemia — always check Ca2+ too
• Tx: calcium replacement (IV or PO), calcium-rich diet • Tx: Mg replacement — oral (mild) or IV MgSO4 (severe)
Hypercalcemia: hyperparathyroidism, cancer, thiazide diuretics, Hypermagnesemia: Mg supplements, kidney failure
immobility • S&S;: absent DTRs, respiratory depression, bradycardia, low BP, coma
• S&S;: muscle weakness, decreased DTRs, confusion, constipation, • Antidote: calcium gluconate; loop diuretics
dysrhythmia
• Tx: IV normal saline (flush Ca2+ out); STOP thiazides & Ca
supplements; cardiac monitoring
■ Acid-Base Interpretation (Ch 14)
Disorder ABG Values Common Causes Treatment
Metabolic Acidosis pH <7.35 HCO3- <22 PaCO2 LOW DKA, renal failure, sepsis, diarrhea Treat cause; sodium bicarbonate if
(compensation — Kussmaul severe; monitor K+
breathing)
Metabolic Alkalosis pH >7.45 HCO3- >26 PaCO2 HIGH Vomiting, NG suction, excess Treat cause; replace Cl-, K+;
(compensation) antacids, diuretics acetazolamide
Respiratory Acidosis pH <7.35 PaCO2 >45 HCO3- HIGH COPD, hypoventilation, sedation, Improve ventilation; bronchodilators;
(compensation) airway obstruction treat cause
Respiratory Alkalosis pH >7.45 PaCO2 <35 HCO3- LOW Anxiety, hyperventilation, pain, Treat cause; breathe into bag (anxiety);
(compensation) mechanical vent slow ventilator rate
QUICK TIP — ABG Steps: (1) Check pH — acidosis <7.35 / alkalosis >7.45 (2) Check PaCO2 — if matches pH = respiratory cause (3) Check
HCO3- — if matches pH = metabolic cause (4) If opposite = compensation
SECTION 2 — CARDIOVASCULAR SYSTEM (Ch 27–30)
■ Dysrhythmias (Ch 28)
Rhythm ECG/HR Clinical Significance Treatment/Action
Sinus Bradycardia HR <60 bpm Symptomatic: dizziness, syncope, Atropine; pacemaker if refractory
hypotension
, Rhythm ECG/HR Clinical Significance Treatment/Action
Sinus Tachycardia HR >100 bpm Usually from cause (pain, fever, Treat underlying cause
hypovolemia)
Atrial Fibrillation Irregularly irregular HR; no distinct P Stroke risk (clot in atria); CO decreases Rate control: diltiazem, metoprolol;
waves; HR >130 = concern 20-30% Rhythm: amiodarone, cardioversion;
ANTICOAGULATION
Ventricular Tachycardia Wide QRS >140 bpm; assess for If pulse: synchronized cardioversion + No pulse: CPR + DEFIBRILLATE +
pulse! amiodarone epinephrine
Ventricular Fibrillation Chaotic rhythm; NO pulse; Cardiac arrest CALL CODE → CPR →
life-threatening DEFIBRILLATE (unsynchronized)
■ A-Fib: Critical Nursing Points
• Cardioversion requires anticoagulation 4-6 WEEKS before (or TEE to • Digoxin toxicity signs: bradycardia, N/V, yellow-green vision, HR <60 →
rule out thrombus) HOLD & notify
• Hold digitalis before cardioversion (controversial — follow order) • Amiodarone toxicity: pulmonary (most serious), thyroid, liver, corneal
• Defibrillation = NO pulse (unsynchronized) | Cardioversion = WITH pulse deposits (visual halos)
(synchronized) • Anticoagulants: warfarin (monitor INR), apixaban/dabigatran (no routine
INR needed)
■ Heart Failure (Ch 29)
Left-Sided HF (pulmonary congestion): MAWDS Heart Failure Teaching:
• Dyspnea on exertion, orthopnea, PND • Medications — one pharmacy; AVOID NSAIDs; never stop BB abruptly
• Frothy pink-tinged sputum (pulmonary edema — EMERGENCY) • Activity — aerobic; can talk while exercising
• Crackles, weak pulses, fatigue, oliguria • Weight — daily morning weights, same scale, after voiding
• Causes: HTN, CAD, valvular disease • Diet — <3g Na/day; 2L fluid restriction
Right-Sided HF (systemic congestion): • Symptoms — report gain of 3 lb/WEEK or 1-2 lb OVERNIGHT
• Pitting edema (lower extremities) Drugs for HF:
• JVD, ascites, hepatomegaly • Diuretics (furosemide) — watch K+ & Mg2+
• Nausea/anorexia from liver engorgement • ACEi/ARBs — cough (ACEi), monitor K+; NO in pregnancy
• Most common cause: left-sided HF • Beta-blockers — hold if HR <60; never stop abruptly
• Digoxin — therapeutic level 0.5-2 ng/mL; hold if HR <60
• Spironolactone — K+-sparing; avoid high-K+ foods
PULMONARY EDEMA EMERGENCY — Priority Sequence:
(1) HIGH-FOWLER'S position → (2) Supplemental O2 → (3) STAY WITH patient, NOTIFY provider → (4) Anticipate: IV furosemide, nitrates,
morphine → (5) Insert Foley for strict I&O;
■ Hypertension (Ch 30)
Classification: PAD vs Venous Insufficiency — KEY DIFFERENCE:
• Normal: <120/80 | Elevated: 120-129/<80 • PAD (arterial): pale, cool, shiny skin; absent pulses; pain with exertion
• Stage 1: 130-139/80-89 | Stage 2: >140/90 (claudication) or rest; keep legs FLAT or dependent
• HTN Crisis: >180/120 with end-organ damage • Venous: brown pigmentation, ulcers on medial ankle; varicosities; keep
• Crisis S&S;: severe HA, blurred vision, nosebleed, dyspnea legs ELEVATED
HTN Drug Classes: • NEVER elevate legs in PAD — worsens arterial blood flow
• Thiazides (HCTZ) — watch K+ (loses K+), Ca2+ (retains) PAD Teaching:
• Loop diuretics (furosemide) — watch K+, Mg2+ • Stop smoking — vasoconstriction worsens disease
• ACEi (lisinopril) — dry cough common; K+ retention; angioedema = • Inspect feet daily; no heating pads; avoid crossing legs
STOP • Properly fitting shoes; never walk barefoot
• ARBs (valsartan) — no cough; K+ retention Anticoagulation/VTE Teaching (Warfarin):
• Beta-blockers — bradycardia; masks hypoglycemia; no abrupt stop • Monitor INR regularly (therapeutic 2-3)
• Ca-channel blockers (diltiazem) — edema, constipation; rate control in • Consistent vitamin K foods — no drastic changes
A-Fib • Report: unusual bleeding, pink/red urine, prolonged bleeding from cuts
• No double-dosing if missed dose
SECTION 3 — URINARY/RENAL DISORDERS (Ch 57–59, 61)
Ch 13–14 Fluids/Electrolytes/Acid-Base | Ch 27–30 Cardiovascular | Ch 57–59, 61, 64 Urinary/Renal/BPH
SECTION 1 — FLUIDS, ELECTROLYTES & ACID-BASE (Ch 13–14)
■ Normal Lab Values to Memorize
Na+ (Sodium) 135-145 K+ (Potassium) 3.5-5.0
Hyponatremia <135: GI loss, diuretics, burns, kidney disease Hypokalemia <3.5: diuretics, D/V, corticosteroids, insulin, albuterol
• S&S;: confusion, seizures, muscle twitching, N/D, weak/bounding pulse • S&S;: muscle weakness, irregular HR, ST depression, constipation
• Tx: 0.9% NS (mild); 3% saline (severe — monitor closely) • ECG: flattened T wave, U wave
• SAFETY: Correct slowly — max 12 mEq/L/24hr or risk osmotic • IV K+: NEVER push — always dilute, max 10 mEq/hr peripheral,
demyelination ensure UO >30 mL/hr first
Hypernatremia >145: dehydration, Cushing syndrome, fever Hyperkalemia >5.0: kidney failure, ACEi/ARBs, acidosis, crush injury,
• S&S;: agitation, confusion, muscle twitching, craves water potassium-sparing diuretics
• Tx: 0.45% NS or D5W (hypotonic), oral fluids, diuretics, Na restriction • S&S;: peaked T waves, bradycardia, dysrhythmia, diarrhea, paresthesia
• Tx: STOP K+ sources; glucose + insulin (shift K+ into cells); calcium
gluconate (cardiac protection FIRST); kayexalate
Ca2+ (Calcium) 8.5-10.5 Mg2+ (Magnesium) 1.8-2.6
Hypocalcemia: inadequate intake, diarrhea, alkalosis, diuretics, Hypomagnesemia: malnutrition, alcohol use, diarrhea, PPIs, diuretics
immobility • S&S;: hyperactive DTRs, Chvostek/Trousseau signs, tetany,
• S&S;: Chvostek sign (facial twitch), Trousseau sign (carpal spasm), dysrhythmia, HTN
tingling/paresthesia, tetany, osteoporosis • Often coexists with hypocalcemia — always check Ca2+ too
• Tx: calcium replacement (IV or PO), calcium-rich diet • Tx: Mg replacement — oral (mild) or IV MgSO4 (severe)
Hypercalcemia: hyperparathyroidism, cancer, thiazide diuretics, Hypermagnesemia: Mg supplements, kidney failure
immobility • S&S;: absent DTRs, respiratory depression, bradycardia, low BP, coma
• S&S;: muscle weakness, decreased DTRs, confusion, constipation, • Antidote: calcium gluconate; loop diuretics
dysrhythmia
• Tx: IV normal saline (flush Ca2+ out); STOP thiazides & Ca
supplements; cardiac monitoring
■ Acid-Base Interpretation (Ch 14)
Disorder ABG Values Common Causes Treatment
Metabolic Acidosis pH <7.35 HCO3- <22 PaCO2 LOW DKA, renal failure, sepsis, diarrhea Treat cause; sodium bicarbonate if
(compensation — Kussmaul severe; monitor K+
breathing)
Metabolic Alkalosis pH >7.45 HCO3- >26 PaCO2 HIGH Vomiting, NG suction, excess Treat cause; replace Cl-, K+;
(compensation) antacids, diuretics acetazolamide
Respiratory Acidosis pH <7.35 PaCO2 >45 HCO3- HIGH COPD, hypoventilation, sedation, Improve ventilation; bronchodilators;
(compensation) airway obstruction treat cause
Respiratory Alkalosis pH >7.45 PaCO2 <35 HCO3- LOW Anxiety, hyperventilation, pain, Treat cause; breathe into bag (anxiety);
(compensation) mechanical vent slow ventilator rate
QUICK TIP — ABG Steps: (1) Check pH — acidosis <7.35 / alkalosis >7.45 (2) Check PaCO2 — if matches pH = respiratory cause (3) Check
HCO3- — if matches pH = metabolic cause (4) If opposite = compensation
SECTION 2 — CARDIOVASCULAR SYSTEM (Ch 27–30)
■ Dysrhythmias (Ch 28)
Rhythm ECG/HR Clinical Significance Treatment/Action
Sinus Bradycardia HR <60 bpm Symptomatic: dizziness, syncope, Atropine; pacemaker if refractory
hypotension
, Rhythm ECG/HR Clinical Significance Treatment/Action
Sinus Tachycardia HR >100 bpm Usually from cause (pain, fever, Treat underlying cause
hypovolemia)
Atrial Fibrillation Irregularly irregular HR; no distinct P Stroke risk (clot in atria); CO decreases Rate control: diltiazem, metoprolol;
waves; HR >130 = concern 20-30% Rhythm: amiodarone, cardioversion;
ANTICOAGULATION
Ventricular Tachycardia Wide QRS >140 bpm; assess for If pulse: synchronized cardioversion + No pulse: CPR + DEFIBRILLATE +
pulse! amiodarone epinephrine
Ventricular Fibrillation Chaotic rhythm; NO pulse; Cardiac arrest CALL CODE → CPR →
life-threatening DEFIBRILLATE (unsynchronized)
■ A-Fib: Critical Nursing Points
• Cardioversion requires anticoagulation 4-6 WEEKS before (or TEE to • Digoxin toxicity signs: bradycardia, N/V, yellow-green vision, HR <60 →
rule out thrombus) HOLD & notify
• Hold digitalis before cardioversion (controversial — follow order) • Amiodarone toxicity: pulmonary (most serious), thyroid, liver, corneal
• Defibrillation = NO pulse (unsynchronized) | Cardioversion = WITH pulse deposits (visual halos)
(synchronized) • Anticoagulants: warfarin (monitor INR), apixaban/dabigatran (no routine
INR needed)
■ Heart Failure (Ch 29)
Left-Sided HF (pulmonary congestion): MAWDS Heart Failure Teaching:
• Dyspnea on exertion, orthopnea, PND • Medications — one pharmacy; AVOID NSAIDs; never stop BB abruptly
• Frothy pink-tinged sputum (pulmonary edema — EMERGENCY) • Activity — aerobic; can talk while exercising
• Crackles, weak pulses, fatigue, oliguria • Weight — daily morning weights, same scale, after voiding
• Causes: HTN, CAD, valvular disease • Diet — <3g Na/day; 2L fluid restriction
Right-Sided HF (systemic congestion): • Symptoms — report gain of 3 lb/WEEK or 1-2 lb OVERNIGHT
• Pitting edema (lower extremities) Drugs for HF:
• JVD, ascites, hepatomegaly • Diuretics (furosemide) — watch K+ & Mg2+
• Nausea/anorexia from liver engorgement • ACEi/ARBs — cough (ACEi), monitor K+; NO in pregnancy
• Most common cause: left-sided HF • Beta-blockers — hold if HR <60; never stop abruptly
• Digoxin — therapeutic level 0.5-2 ng/mL; hold if HR <60
• Spironolactone — K+-sparing; avoid high-K+ foods
PULMONARY EDEMA EMERGENCY — Priority Sequence:
(1) HIGH-FOWLER'S position → (2) Supplemental O2 → (3) STAY WITH patient, NOTIFY provider → (4) Anticipate: IV furosemide, nitrates,
morphine → (5) Insert Foley for strict I&O;
■ Hypertension (Ch 30)
Classification: PAD vs Venous Insufficiency — KEY DIFFERENCE:
• Normal: <120/80 | Elevated: 120-129/<80 • PAD (arterial): pale, cool, shiny skin; absent pulses; pain with exertion
• Stage 1: 130-139/80-89 | Stage 2: >140/90 (claudication) or rest; keep legs FLAT or dependent
• HTN Crisis: >180/120 with end-organ damage • Venous: brown pigmentation, ulcers on medial ankle; varicosities; keep
• Crisis S&S;: severe HA, blurred vision, nosebleed, dyspnea legs ELEVATED
HTN Drug Classes: • NEVER elevate legs in PAD — worsens arterial blood flow
• Thiazides (HCTZ) — watch K+ (loses K+), Ca2+ (retains) PAD Teaching:
• Loop diuretics (furosemide) — watch K+, Mg2+ • Stop smoking — vasoconstriction worsens disease
• ACEi (lisinopril) — dry cough common; K+ retention; angioedema = • Inspect feet daily; no heating pads; avoid crossing legs
STOP • Properly fitting shoes; never walk barefoot
• ARBs (valsartan) — no cough; K+ retention Anticoagulation/VTE Teaching (Warfarin):
• Beta-blockers — bradycardia; masks hypoglycemia; no abrupt stop • Monitor INR regularly (therapeutic 2-3)
• Ca-channel blockers (diltiazem) — edema, constipation; rate control in • Consistent vitamin K foods — no drastic changes
A-Fib • Report: unusual bleeding, pink/red urine, prolonged bleeding from cuts
• No double-dosing if missed dose
SECTION 3 — URINARY/RENAL DISORDERS (Ch 57–59, 61)
