NSG 170 Fluids and Electrolytes Exam
with Complete Solutions
What changes in vitals could indicate a patient has extracellular fluid volume (ECV)
EXCESS? - ANS-- 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? - ANS-- 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? - ANS-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? - ANS-to keep open
What does KVO stand for? - ANS-keep vein open
What does EID stand for? - ANS-electronic infusion device
insensible water loss - ANS-Normal daily insensible fluid loss is 600 - 900 per day
(sweat, stool, etc.)
Infiltration - ANS-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 - ANS-Inflammation of inner layer of a vein as a result of chemical, mechanical,
or bacterial causes.
Symptoms: Pain, tenderness, redness
Extravasation - ANS-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 - ANS-IV solution infused too rapidly or in too great
an amount.
What assessment findings are present with extracellular fluid volume (ECV) excess with
NA+ - ANS-- 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? - ANS--
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? - ANS-- 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? -
ANS-- Cardiac dysrhythmias
- Muscle weakness
- Abdominal distention
How often do you assess a vascular access devise (VAD) site? - ANS-- At least every 4
hours (on oriented adult)
- At least every 1 to 2 hours for critically ill patients and patients receiving sedatives
- At least every hour for neonates and children
What size correlates with a green catheter? - ANS-18g (one of the most common)
USED FOR:
- Administering blood
- Pushing rapid fluids
What size correlates with a pink catheter? - ANS-20g (one of the common sizes)
USED FOR:
- Adults
- Can be used for blood admin if can't find larger catheter.
, - Continual infusions
What size correlates with a blue catheter? - ANS-22g (one of the common sizes)
USED FOR:
- Used for non-critically ill patients who will not require IV for long period
- Small/fragile veins
What size correlates with a grey catheter? - ANS-16g (less common)
USED FOR:
- ICU or surgical - for rapid infusion
What size correlates with a yellow catheter? - ANS-24g
USED FOR:
- Pediatric patients
- Patients with very small veins
Steps for IV insertion: - ANS-1) Explain procedure
2) Hand hygiene
3) Gather equipment
4) Flush NS into extension set
5) Apply tourniquet
6) Select site - take your time to be sure you select a good site
7) Clean site
8) Insert needle (bevel up!)
9) Advance catheter when flashback is noted!
10) Remove tourniquet
11) Ensure catheter is advanced completely and remove needle
with Complete Solutions
What changes in vitals could indicate a patient has extracellular fluid volume (ECV)
EXCESS? - ANS-- 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? - ANS-- 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? - ANS-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? - ANS-to keep open
What does KVO stand for? - ANS-keep vein open
What does EID stand for? - ANS-electronic infusion device
insensible water loss - ANS-Normal daily insensible fluid loss is 600 - 900 per day
(sweat, stool, etc.)
Infiltration - ANS-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 - ANS-Inflammation of inner layer of a vein as a result of chemical, mechanical,
or bacterial causes.
Symptoms: Pain, tenderness, redness
Extravasation - ANS-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 - ANS-IV solution infused too rapidly or in too great
an amount.
What assessment findings are present with extracellular fluid volume (ECV) excess with
NA+ - ANS-- 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? - ANS--
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? - ANS-- 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? -
ANS-- Cardiac dysrhythmias
- Muscle weakness
- Abdominal distention
How often do you assess a vascular access devise (VAD) site? - ANS-- At least every 4
hours (on oriented adult)
- At least every 1 to 2 hours for critically ill patients and patients receiving sedatives
- At least every hour for neonates and children
What size correlates with a green catheter? - ANS-18g (one of the most common)
USED FOR:
- Administering blood
- Pushing rapid fluids
What size correlates with a pink catheter? - ANS-20g (one of the common sizes)
USED FOR:
- Adults
- Can be used for blood admin if can't find larger catheter.
, - Continual infusions
What size correlates with a blue catheter? - ANS-22g (one of the common sizes)
USED FOR:
- Used for non-critically ill patients who will not require IV for long period
- Small/fragile veins
What size correlates with a grey catheter? - ANS-16g (less common)
USED FOR:
- ICU or surgical - for rapid infusion
What size correlates with a yellow catheter? - ANS-24g
USED FOR:
- Pediatric patients
- Patients with very small veins
Steps for IV insertion: - ANS-1) Explain procedure
2) Hand hygiene
3) Gather equipment
4) Flush NS into extension set
5) Apply tourniquet
6) Select site - take your time to be sure you select a good site
7) Clean site
8) Insert needle (bevel up!)
9) Advance catheter when flashback is noted!
10) Remove tourniquet
11) Ensure catheter is advanced completely and remove needle
