NUR242 Exam 2 Galen UPDATED
ACTUAL Exam Questions and CORRECT
Answers
Causes of fluid overload - CORRECT ANSWER - •Excessive fluid replacement
•Kidney failure (late phase)
•Heart failure
•Long term corticosteroid therapy
•Syndrome of inappropriate antidiuretic hormone (SIADH)
•Psychiatric disorders with polydipsia
•Water intoxication
s/s fluid overload - CORRECT ANSWER - •CV: tachycardia, bounding pulse, HTN,
decrease pulse pressure, JVD, weight gain
•Resp: increase and shallow resp; SOB, crackles lung sounds
•Skin: pitting edema, skin pale and cool to touch
•Neuromuscular: LOC, HA, visual disturbance, muscle weakness, paresthesia
•GI: increase motility, enlarge liver
Assessment for fluid overload - CORRECT ANSWER - •Assess risk r/t age and
diagnosis, history (overhydration, CHF, kidney disease)
•Assess vital signs why: watch for bounding tachycardia, HTN, dysrhythmias, tachypnea
•Assess lung sounds (crackles) , weight, LOC, Observe JVD
•Assess lab values: electrolytes imbalance and signs and symptoms
• Focus Assessment: skin/extremities/ abdomen and sacrum area for edema
•Assess perfusion: edema may impair perfusion to extremities, assess peripheral and central
pulses, capillary refill, skin color, temp, sensory and motor function
•Observe for urine output
,Lab values fluid overload - CORRECT ANSWER - •Serum osmolality (275-295
mOsm/kg)
•Decrease found in overhydration <275; and < 265 is critical finding
•CBC
•Decrease hemoglobin and hematocrit
•BUN
•decreased BUN
•Electrolytes
•Decreased sodium (shifts due to dilution)
•Urine specific gravity Decrease < 1.005
fluid overload interventions/goal - CORRECT ANSWER - •Goal: reduce excess body
fluids, promote desired elimination
•Manage underlying cause
•Restrict dietary sodium intake
•Monitor I/O
•Administer diuretic
•Monitor client's s/s and electrolytes values
•Restrict oral and other fluid intake as prescribed
Fluid overload complications - CORRECT ANSWER - •Isotonic overhydration
•HF and pulmonary edema
•Seizure
•Coma
Fluid overload medications - CORRECT ANSWER - Furosemide
Mannitol
, S/S of dehydration - CORRECT ANSWER - •Vital signs: hyperthermia, ST, thread pulse,
hypotension, decrease CVP
•Neuromusculoskeletal: Dizziness, syncope, confusion, weakness, fatigue
•GI: thirst, dry furrowed tongue, N/V, anorexia, weight loss
•Renal: Oliguria
•Other signs: Diminish capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flat neck
vein
Dehydration assessment - CORRECT ANSWER - •Assess for condition leading to
dehydration: diarrhea, poor intake, vigorous exercise, vomiting, polyuria, fluid losses (burns,
trauma) clients with drains/NG tube, burns/fluid shifts, overuse of diuretic
Dehydration labs - CORRECT ANSWER - •Serum electrolytes (hypernatremia)
•Increased serum osmolality normal 275- 295 mOsm/kg; elevated > 295 found in dehydration; >
320 is critical finding
•CBC elevated H/H
•Elevated urine specific gravity > 1.030
•Increased BUN
Dehydration interventions/goal - CORRECT ANSWER - •Goal of interventions: replace
fluid and electrolytes to achieve homeostasis
•Closely monitor status and rehydration, avoid overcorrection
•Monitor I/O and weight
•Identify and manage cause- diarrhea, vomiting, blood loss, poor intake
•Oral rehydration is priority if tolerating PO fluids
Dehydration priority interventions - CORRECT ANSWER - •IV fluid
resuscitation/replacement, general guidelines
•Hypertonic dehydration- hypotonic fluids- D5W once dextrose is metabolized; 0.45% NaCL
(1/2 normal saline)
ACTUAL Exam Questions and CORRECT
Answers
Causes of fluid overload - CORRECT ANSWER - •Excessive fluid replacement
•Kidney failure (late phase)
•Heart failure
•Long term corticosteroid therapy
•Syndrome of inappropriate antidiuretic hormone (SIADH)
•Psychiatric disorders with polydipsia
•Water intoxication
s/s fluid overload - CORRECT ANSWER - •CV: tachycardia, bounding pulse, HTN,
decrease pulse pressure, JVD, weight gain
•Resp: increase and shallow resp; SOB, crackles lung sounds
•Skin: pitting edema, skin pale and cool to touch
•Neuromuscular: LOC, HA, visual disturbance, muscle weakness, paresthesia
•GI: increase motility, enlarge liver
Assessment for fluid overload - CORRECT ANSWER - •Assess risk r/t age and
diagnosis, history (overhydration, CHF, kidney disease)
•Assess vital signs why: watch for bounding tachycardia, HTN, dysrhythmias, tachypnea
•Assess lung sounds (crackles) , weight, LOC, Observe JVD
•Assess lab values: electrolytes imbalance and signs and symptoms
• Focus Assessment: skin/extremities/ abdomen and sacrum area for edema
•Assess perfusion: edema may impair perfusion to extremities, assess peripheral and central
pulses, capillary refill, skin color, temp, sensory and motor function
•Observe for urine output
,Lab values fluid overload - CORRECT ANSWER - •Serum osmolality (275-295
mOsm/kg)
•Decrease found in overhydration <275; and < 265 is critical finding
•CBC
•Decrease hemoglobin and hematocrit
•BUN
•decreased BUN
•Electrolytes
•Decreased sodium (shifts due to dilution)
•Urine specific gravity Decrease < 1.005
fluid overload interventions/goal - CORRECT ANSWER - •Goal: reduce excess body
fluids, promote desired elimination
•Manage underlying cause
•Restrict dietary sodium intake
•Monitor I/O
•Administer diuretic
•Monitor client's s/s and electrolytes values
•Restrict oral and other fluid intake as prescribed
Fluid overload complications - CORRECT ANSWER - •Isotonic overhydration
•HF and pulmonary edema
•Seizure
•Coma
Fluid overload medications - CORRECT ANSWER - Furosemide
Mannitol
, S/S of dehydration - CORRECT ANSWER - •Vital signs: hyperthermia, ST, thread pulse,
hypotension, decrease CVP
•Neuromusculoskeletal: Dizziness, syncope, confusion, weakness, fatigue
•GI: thirst, dry furrowed tongue, N/V, anorexia, weight loss
•Renal: Oliguria
•Other signs: Diminish capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flat neck
vein
Dehydration assessment - CORRECT ANSWER - •Assess for condition leading to
dehydration: diarrhea, poor intake, vigorous exercise, vomiting, polyuria, fluid losses (burns,
trauma) clients with drains/NG tube, burns/fluid shifts, overuse of diuretic
Dehydration labs - CORRECT ANSWER - •Serum electrolytes (hypernatremia)
•Increased serum osmolality normal 275- 295 mOsm/kg; elevated > 295 found in dehydration; >
320 is critical finding
•CBC elevated H/H
•Elevated urine specific gravity > 1.030
•Increased BUN
Dehydration interventions/goal - CORRECT ANSWER - •Goal of interventions: replace
fluid and electrolytes to achieve homeostasis
•Closely monitor status and rehydration, avoid overcorrection
•Monitor I/O and weight
•Identify and manage cause- diarrhea, vomiting, blood loss, poor intake
•Oral rehydration is priority if tolerating PO fluids
Dehydration priority interventions - CORRECT ANSWER - •IV fluid
resuscitation/replacement, general guidelines
•Hypertonic dehydration- hypotonic fluids- D5W once dextrose is metabolized; 0.45% NaCL
(1/2 normal saline)
