QUESTIONS WITH SOLUTIONS GRADED A+
◉ fluid volume deficit nursing interventions. Answer: intake/output,
cardiovascular changes, LOC changes, pupillary response,
responsiveness, voluntary movement, patient safety, seizure
precautions, fall precautions, daily weights, skin assessment for
turgor/color/dryness, pitting edema, administer IV fluids
◉ dehydration. Answer: loss of water alone without sodium, cell
shrinks
◉ hypernatremia causes. Answer: sodium greater than 145, intake
excessive, IV fluids (hypertonic Nacl, IV sodium bicarbonate),
hypertonic tube feedings without water supplements, near-
drowning in salt water, inadequate water intake (cog impaired),
excessive water loss (heatstroke, high fever), osmotic diuretic
therapy, diarrhea, disease states like DI, primary
hyperaldosteronism, cushing syndrome, uncontrolled diabetes
mellitus
◉ hypernatremia; fluid volume deficit signs/symptoms. Answer:
signs of thirst, fever, dry mucous membranes, hypotension,
tachycardia, low jugular venous pressure and restlessness,
weakness, change of LOC, thready pulses
,◉ nursing management of hypernatremia. Answer: administer
hypotonic solution if na known, administer isotonic solution if na is
not known, if corrected too quickly can cause cerebral edema
◉ hypernatremia nursing interventions. Answer: treat the cause,
add water to balance sodium, or replace sodium and water, monitor
I/O, urine specific gravity greater than 1.025, pulses, tachycardia,
tachypnea, changes in sensorium, daily weights, skin turgor and
mucous membranes
◉ which of the follow interventions does the nurse complete when
caring for a client admitted with a sodium level of 152 mEq/L.
Answer: observe and prepare for possible seizures
◉ hyponatremia causes. Answer: sodium is less than 135 mEq/L,
vomiting, diuretics, gastrointestinal suctioning, diarrhea, inadequate
salt intake, fluid shift from the ICF to the ECF by hypertonic
solutions which leads to dilutional hyponatremia
◉ two phases of hyponatremia. Answer: 1 is too much volume, so
decrease in sodium to correct give diuretic and 2 is loss of sodium
from other sources to correct on individual basis
, ◉ decreased Na is caused by dilution as a result of. Answer: excess
water or increased Na loss
◉ hyponatremia signs and symptoms. Answer: cell swells, lethargy,
headache, confusion, apprehension, seizures, and coma, change in
LOC, muscle weakness, stupor, tendon reflexes decreases
◉ hyponatremia interventions. Answer: administer hypertonic
solutions with known Na value, monitor patients lungs sounds,
administer isotonic solutions with unknown sodium level, report
LOC changes, fluid restriction if caused by too much water
◉ nursing management of hyponatremia. Answer: I/O, check for
bounding pulses, bulging neck veins, BP changes, signs of cerebral
edema, daily weights, pitting edema with fluid excess, daily weights
and goal is to restore na and water balance and prevent
complications of cerebral edema
◉ the nurse assigned to a client with hyponatremia would conclude
that which of the following factors probably contributed to this
electrolyte imbalance. Answer: fluid retention and heart failure
◉ potassium imbalances. Answer: heart contractions and ECG will
guide plan of care