NS 660 EXAM 2 QUESTIONS AND ANSWERS | LATEST UPDATE 100% SOLVED
Describe processes involved in regulating acid-base balance (3) Acid buffering: H3O buffer in
the ECF
Acid production: Cells produce CO2, other metabolic acids include lactic acid
Acid excretion: Lungs exhale CO2, kidneys excrete everything except carbonic acid
Apply nursing process when caring for patients with fluid, electrolyte, acid-base imbalances.
Assess: Vitals, daily weights, 24hr I+Os, lab values (baselines and trends)
Diagnose: Deficient fluid volume, acute confusion, impaired gas exchange, excess fluid volume,
risk for electrolyte imbalance, deficient knowledge regarding disease management, risk for
injury, decreased CO.
Each Dx should only include 1 problem.
Planning: Goals + outcomes (SMART), individual plan of care for each nursing Dx, plan for
potential interventions + required material/equipment.
Intervention: Health promotion (education), risk reduction, acute care - PO fluid replacement,
fluid restriction, IV therapy (fluid, electrolytes, blood products)
,Evaluate: Assess effects of intervention (reassess labs, etc). Check in w/ patient.
Identify tonicity of types of IV fluids and discuss impact on cell, therapeutic uses, and
contraindications to use. Isotonic:
0.9% sodium chloride (NS) [NS is only solution that cane be used with blood products]
Lactated ringers
Dextrose 5% water (D5W) - enters as isotonic -> metabolize dextrose -> free H2O -> becomes
hypotonic.
Isotonic solutions expand ECF volume (vascular + interstitial), no fluid shifts, cells same size.
*watch for s/s fluid overload
Hypotonic:
0.45% NS "half normal"
Less solutes than intracellular fluid, Cell wall swells
used for hydration
Hypertonic:
3.5% sodium chloride, Dextrose 5% in 0.45% sodium chloride, D5 in 0.9%, D5 in lactated ringers
More solutes than intracellular fluid, fluid shifts out of cell -> cell shrinks
Used for hypovolemia, vascular expansion
Describe potential complication of vascular access devices:
,Phlebitis
Infiltration
Extravasation Assess IV every 4hrs, 2hrs if critical/coma
Phlebitis: Infection, red, warmth, tender - chemical, bacterial, mechanical
Infiltration: Leak of fluid around puncture site. Cool, pale, swollen skin - dislodging of IV
(mechanical)
Extravasation: Deep wound. Cool, pale, swollen skin
Identify types of vascular access devices (3) Central line/CVAD: long-term use. Catheter tip
and superior vena cava. Some require surgical insertion. Concerns for CLABSIs
PICC line: Peripherally inserted central catheter. Peripheral arm vein, terminates at superior
vena cava. 3 lines in 1 site.
Peripheral IV: short term use. 18 gauge (blood transfusion), large IV.
Describe different blood transfusion reactions and interventions to manage them.
Hemolytic:
, ABO compatibility error (antibodies attack donor antigens). Chills, fever, tachycardia,
hypotension, flushing
Nonhemolytic:
Febrile. Antibodies attack donor WBCs. rigors, headache, flushing
Minor allergic:
Uticaria (hives)
Anaphylactic:
Lethal reaction. Within 10mL/first 15 min of infusion
STOP infusion, administer NS in NEW line, notify provider, stay with patient.
Appropriate techniques for physical assessment of cardiovascular system. Manual BP,
Palpate: for peripheral edema, JVD
Inspect: coloring (cyanosis), pulse pressure
symmetry
Auscultate: APE to MAN, normal heart sounds, s3, s4, murmurs, symmetry
Need multiple BP readings for hypertension Dx. Wait 30 min. No caffeine or smoking
Describe processes involved in regulating acid-base balance (3) Acid buffering: H3O buffer in
the ECF
Acid production: Cells produce CO2, other metabolic acids include lactic acid
Acid excretion: Lungs exhale CO2, kidneys excrete everything except carbonic acid
Apply nursing process when caring for patients with fluid, electrolyte, acid-base imbalances.
Assess: Vitals, daily weights, 24hr I+Os, lab values (baselines and trends)
Diagnose: Deficient fluid volume, acute confusion, impaired gas exchange, excess fluid volume,
risk for electrolyte imbalance, deficient knowledge regarding disease management, risk for
injury, decreased CO.
Each Dx should only include 1 problem.
Planning: Goals + outcomes (SMART), individual plan of care for each nursing Dx, plan for
potential interventions + required material/equipment.
Intervention: Health promotion (education), risk reduction, acute care - PO fluid replacement,
fluid restriction, IV therapy (fluid, electrolytes, blood products)
,Evaluate: Assess effects of intervention (reassess labs, etc). Check in w/ patient.
Identify tonicity of types of IV fluids and discuss impact on cell, therapeutic uses, and
contraindications to use. Isotonic:
0.9% sodium chloride (NS) [NS is only solution that cane be used with blood products]
Lactated ringers
Dextrose 5% water (D5W) - enters as isotonic -> metabolize dextrose -> free H2O -> becomes
hypotonic.
Isotonic solutions expand ECF volume (vascular + interstitial), no fluid shifts, cells same size.
*watch for s/s fluid overload
Hypotonic:
0.45% NS "half normal"
Less solutes than intracellular fluid, Cell wall swells
used for hydration
Hypertonic:
3.5% sodium chloride, Dextrose 5% in 0.45% sodium chloride, D5 in 0.9%, D5 in lactated ringers
More solutes than intracellular fluid, fluid shifts out of cell -> cell shrinks
Used for hypovolemia, vascular expansion
Describe potential complication of vascular access devices:
,Phlebitis
Infiltration
Extravasation Assess IV every 4hrs, 2hrs if critical/coma
Phlebitis: Infection, red, warmth, tender - chemical, bacterial, mechanical
Infiltration: Leak of fluid around puncture site. Cool, pale, swollen skin - dislodging of IV
(mechanical)
Extravasation: Deep wound. Cool, pale, swollen skin
Identify types of vascular access devices (3) Central line/CVAD: long-term use. Catheter tip
and superior vena cava. Some require surgical insertion. Concerns for CLABSIs
PICC line: Peripherally inserted central catheter. Peripheral arm vein, terminates at superior
vena cava. 3 lines in 1 site.
Peripheral IV: short term use. 18 gauge (blood transfusion), large IV.
Describe different blood transfusion reactions and interventions to manage them.
Hemolytic:
, ABO compatibility error (antibodies attack donor antigens). Chills, fever, tachycardia,
hypotension, flushing
Nonhemolytic:
Febrile. Antibodies attack donor WBCs. rigors, headache, flushing
Minor allergic:
Uticaria (hives)
Anaphylactic:
Lethal reaction. Within 10mL/first 15 min of infusion
STOP infusion, administer NS in NEW line, notify provider, stay with patient.
Appropriate techniques for physical assessment of cardiovascular system. Manual BP,
Palpate: for peripheral edema, JVD
Inspect: coloring (cyanosis), pulse pressure
symmetry
Auscultate: APE to MAN, normal heart sounds, s3, s4, murmurs, symmetry
Need multiple BP readings for hypertension Dx. Wait 30 min. No caffeine or smoking
