NR 324 ADULT HEALTH 1 EXAM UPDATED ACTUAL QUESTIONS AND CORRECT ANSWERS

NR 324 ADULT HEALTH 1 EXAM UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS

Question:
What age group has the highest percentage of water content?
Answer:
Preterm / Neonates

Question:
Two fluid compartments in the body
Answer:
Intracellular space (inside cells) located in the ICF Extracellular space (outside cells)
located in the ECF

Question:
ICF makes up what percent of total body weight?
Answer:
40%

Question:
What are the two main compartments containing ECF? What other compartments are
there?
Answer:
Interstitial fluid (fluid in the spaces between cells) Intravascular fluid (plasma) Other
compartments include lymph and transcellular fluids

Question:
Transcellular fluid includes
Answer:
Cerebrospinal fluid, fluid in the gastrointestinal tract, and joint spaces as well as
pleural, peritoneal, intraocular, and pericardial fluid.

Question:
1L of water = _____ lb.
Answer:
2.2 lb (1kg)

Question:
The concentrations of electrolytes in body fluids is expressed in _________
Answer:
milliequivalents (mEq) per Liter

,Question:
What are the main Ions found in the ECF and ICF
Answer:
ECF 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.

Question:
Hypovolemia (ECF volume deficit)
Answer:
abnormal loss of normal body fluids, (D/V, hemorrhage,
polyuria) inadequate intake, or plasma-to-interstitial fluid shift

Question:
Fluid volume deficit Assessment- Causes-Treatment-Client education
Answer:
Assessment- 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

Question:
Hypervolemia (ECF volume excess)
Answer:
Excessive intake of fluids, abnormal retention of fluids (HF or renal failure), or
interstitial-to-plasma fluid shift

,Question:
Fluid volume excess Assessment- Causes-Treatment-Client education
Answer:
Assessment- • 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

Question:
Nutrition related to potassium
Answer:
Diet is the source -Fruit, dried fruits and vegetables -Many salt substitutes contain
substantial K+

Question:
Nutrition related to sodium
Answer:
-Daily intake far exceeds bodys daily requirments -Glucose promotes sodium and water
absorption

Question:
Hypertonic solutions
Answer:
initially 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

Question:
Isotonic solutions
Answer:
has 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

, Question:
Hypotonic solutions
Answer:
solution 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

Question:
As a nurse it is important to remember what administration guidelines when
administering IV KCL?
Answer:
• 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.

Question:
Hypernatremia
Answer:
Occurs when either too much water is lost or not enough water intake, or too much salt
is taken in

Question:
What S/S should the nurse look for when a patient is experiencing hypernatremia with
decreased, normal and increased ECF volume?
Answer:
Hypernatremia 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

Question:
Sodium plays a key role in the body by...
Answer:
Transmitting nerve impulses

Question:
Hyponatremia
Answer:
Occurs 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