NUR 215 TEST 5 QUESTIONS WITH
CORRECT ANSWERS
Things to consider when evaluating fluid balance: ANSWER: Look for oedema.
Stable blood pressure and pink mucous membranes that are moist
Lung noises (crackles?) (fluid loves the lungs?)
- daily weights - skin turgor
Two fluid balance/electrolyte diagnoses: ANSWER: fluid deficiency - fluid
overflow
stage of implementation for nurses during electrolyte imbalance and fluid
balance: ANSWER; lift legs; reduce sodium intake; record I/Os; and record
daily weights
chambers for fluids—ANSWER Approximately 65% of the body's water is
found inside cells as intracellular fluid (ICF).
About 35% of the body's water outside of cells is called extracellular fluid
(ECF).
Water readily moves between the two compartments.
Hypervolemia: An excess of fluid outside of cells that can cause confusion
For example: -increased blood pressure
Edema
objective: use a ted hose and raise the feet to restore equilibrium.
The ANSWER fluid deficit is hypovalemia.
For example, dry mucous membranes, tachycardia, and a drop in blood pressure
- raise the pulse
, - low blood pressure
Reduce urine, raise BUN, and raise creatinine.
Potassium (K) sources: ANSWER diet: orange juice IV, spinach, bananas,
potatoes, and oral medication
*If their vitamin K levels are too high, raise their BM to get rid of it.
3.5–5.0 range
Sodium (Na) can cause swelling in the brain because it stimulates muscle and
nerve cells.
135–145
Home safety with oxygen ANSWER: No smoking within 10 feet of oxygen in
use; post a sign that reads "no smoking" or "oxygen in use" on the front door; be
aware of the location of the fire extinguisher; avoid wearing wool or synthetic
clothing; make sure all electrical equipment is in good operating order; make
sure that electric machinery is grounded; and avoid using flammable materials
(such as acetone or alcohol) close to oxygen.
seizure precautions: ANSWER; have rescue equipment (oxygen, suction
equipment, oral airway, padding for side rails) at the patient's bedside; have
saline locked in place for the intravenous line; check the surroundings for
potential hazards that could injure the patient during a seizure; help the patient
walk and transfer; advise family members and caregivers not to put anything in
the patient's mouth during a seizure other than an airway; advise others not to
restrain the patient during a seizure but to lower to the ground, remove any
potentially dangerous equipment nearby, protect the client's head, provide
privacy, put the patient on their side, flex their head slightly, and loosen their
clothes.
Since the patient has a significant risk of seizures, what equipment is most
important?
Side rails with padding, oxygen, and a saline lock in place
c. saline lock in place d. everything said above - ANSWER
CORRECT ANSWERS
Things to consider when evaluating fluid balance: ANSWER: Look for oedema.
Stable blood pressure and pink mucous membranes that are moist
Lung noises (crackles?) (fluid loves the lungs?)
- daily weights - skin turgor
Two fluid balance/electrolyte diagnoses: ANSWER: fluid deficiency - fluid
overflow
stage of implementation for nurses during electrolyte imbalance and fluid
balance: ANSWER; lift legs; reduce sodium intake; record I/Os; and record
daily weights
chambers for fluids—ANSWER Approximately 65% of the body's water is
found inside cells as intracellular fluid (ICF).
About 35% of the body's water outside of cells is called extracellular fluid
(ECF).
Water readily moves between the two compartments.
Hypervolemia: An excess of fluid outside of cells that can cause confusion
For example: -increased blood pressure
Edema
objective: use a ted hose and raise the feet to restore equilibrium.
The ANSWER fluid deficit is hypovalemia.
For example, dry mucous membranes, tachycardia, and a drop in blood pressure
- raise the pulse
, - low blood pressure
Reduce urine, raise BUN, and raise creatinine.
Potassium (K) sources: ANSWER diet: orange juice IV, spinach, bananas,
potatoes, and oral medication
*If their vitamin K levels are too high, raise their BM to get rid of it.
3.5–5.0 range
Sodium (Na) can cause swelling in the brain because it stimulates muscle and
nerve cells.
135–145
Home safety with oxygen ANSWER: No smoking within 10 feet of oxygen in
use; post a sign that reads "no smoking" or "oxygen in use" on the front door; be
aware of the location of the fire extinguisher; avoid wearing wool or synthetic
clothing; make sure all electrical equipment is in good operating order; make
sure that electric machinery is grounded; and avoid using flammable materials
(such as acetone or alcohol) close to oxygen.
seizure precautions: ANSWER; have rescue equipment (oxygen, suction
equipment, oral airway, padding for side rails) at the patient's bedside; have
saline locked in place for the intravenous line; check the surroundings for
potential hazards that could injure the patient during a seizure; help the patient
walk and transfer; advise family members and caregivers not to put anything in
the patient's mouth during a seizure other than an airway; advise others not to
restrain the patient during a seizure but to lower to the ground, remove any
potentially dangerous equipment nearby, protect the client's head, provide
privacy, put the patient on their side, flex their head slightly, and loosen their
clothes.
Since the patient has a significant risk of seizures, what equipment is most
important?
Side rails with padding, oxygen, and a saline lock in place
c. saline lock in place d. everything said above - ANSWER
