NU 157 Exam 1 With
Complete Solution
What hormones can affect fluid balance - ANSWER ADH and aldosterone
what are the s/s of fluid volume overload - ANSWER weight gain, slow
bounding pulse, increase BP, edema, crackles in lungs, decrease serum
sodium, decreased hematocrit, and low urine specific gravity w/ high vol
(hypervolemia)
how would you know if a patient is experiencing circulatory overload or
speed shock when receiving IV fluids - ANSWER slow bounding pulse (s/s of
fluid overload)
what are the s/s of fluid volume deficit - ANSWER thirst, poor turgor, weight
loss, dizziness, decrease urine, dry tongue/lips, dry mucous membranes, fast
weak pulse, increase temp, increase H&H, and high urine specific gravity with
low vol (hypovolemia)
what are the nursing interventions for a patient with fluid volume deficit -
ANSWER administer IV fluids as ordered, provide adequate fluid intake if
they can't do themselves, and encourage drinking
what are the types of isotonic IV fluids - ANSWER 5% dextrose in water, 0.9%
saline, 5% in 0.225% dextrose in saline, ringer solution, and lactated ringer
(hartmann solution)
what are the nursing implications associated with receiving TPN - ANSWER
,given via central line, monitor blood glucose, monitor site for infection, 2
nurses check order, and hang sugar solution if TPN runs out until other TPN
is started
what are the s/s of IV infiltration - ANSWER swollen arm, tender, cool to
touch, catheter may or may not have blood return. remove catheter and
restart in other extremity
what are common causes of electrolyte imbalances and who is most at risk -
ANSWER causes: impaired swallowing, weakness, disorientation or coma,
water unavailable, excessive fluid loss (vomiting, diarrhea, hemorrhaging,
diaphoreses, etc)
at risk: elder and infants
normal range for sodium - ANSWER 135-145 mEg/L
normal range for potassium - ANSWER 3.5-5.0 mEq/L
normal range for calcium - ANSWER 9-10.5 mg/dl
normal range for magnesium - ANSWER 1.5-2.5 mEq/L
what are the s/s of hypokalemia - ANSWER abdominal pain, dysrhythmia,
muscle weakness, decreased reflexes, paralysis, urinary retention, increased
urine pH, confusion, and ECG changes
what are the nursing intervention for a patient with hypernatremia -
ANSWER encourage fluid intake, I&O, give water between tube feedings,
restrict sodium intake, and monitor temp
what are the s/s of hypocalcemia - ANSWER paresthesias, cramps/spasms,
weak pulse, decrease BP, + chvostek/trousseau sign, dysrhythmia, dyspnea,
, wheezing, difficulty swallowing, and cardiac failure
what are the s/s of hypermagnesemia - ANSWER hypotension,
sweating/flushing, nausea/vomiting, weakness, paralysis, respiratory
depression, and cardiac dysrhythmias
what electrolyte imbalance is common with renal failure - ANSWER
hyper/hypokalemia
what are the causes of respiratory acidosis - ANSWER slow shallow
respiration (hypoventilation), respiratory congestion or obstruction
what is the cause of respiratory alkalosis - ANSWER hyperventilation
(anxiety), high fever, or overdose of aspirin
what are the causes of metabolic alkalosis - ANSWER vomiting, excessive
antacid intake, extensive GI suction, and hypokalemia
what are the causes of metabolic acidosis - ANSWER sepsis, shock (poor
circulation), DKA, renal failure, hyperkalemia, and diarrhea
what are the nursing interventions for respiratory acidosis - ANSWER oxygen
administration, deep breathing treatments, incentive spirometer,
broncholdilators, and antibiotics
what are the nursing interventions for metabolic acidosis - ANSWER insulin
give with DKA, treating underlying causes, and administer IV sodium
bicarbonate
what are the nursing interventions for respiratory alkalosis - ANSWER
breathing through a brown bag and sedatives
what are complication associated with catherization - ANSWER CAUTI -
Complete Solution
What hormones can affect fluid balance - ANSWER ADH and aldosterone
what are the s/s of fluid volume overload - ANSWER weight gain, slow
bounding pulse, increase BP, edema, crackles in lungs, decrease serum
sodium, decreased hematocrit, and low urine specific gravity w/ high vol
(hypervolemia)
how would you know if a patient is experiencing circulatory overload or
speed shock when receiving IV fluids - ANSWER slow bounding pulse (s/s of
fluid overload)
what are the s/s of fluid volume deficit - ANSWER thirst, poor turgor, weight
loss, dizziness, decrease urine, dry tongue/lips, dry mucous membranes, fast
weak pulse, increase temp, increase H&H, and high urine specific gravity with
low vol (hypovolemia)
what are the nursing interventions for a patient with fluid volume deficit -
ANSWER administer IV fluids as ordered, provide adequate fluid intake if
they can't do themselves, and encourage drinking
what are the types of isotonic IV fluids - ANSWER 5% dextrose in water, 0.9%
saline, 5% in 0.225% dextrose in saline, ringer solution, and lactated ringer
(hartmann solution)
what are the nursing implications associated with receiving TPN - ANSWER
,given via central line, monitor blood glucose, monitor site for infection, 2
nurses check order, and hang sugar solution if TPN runs out until other TPN
is started
what are the s/s of IV infiltration - ANSWER swollen arm, tender, cool to
touch, catheter may or may not have blood return. remove catheter and
restart in other extremity
what are common causes of electrolyte imbalances and who is most at risk -
ANSWER causes: impaired swallowing, weakness, disorientation or coma,
water unavailable, excessive fluid loss (vomiting, diarrhea, hemorrhaging,
diaphoreses, etc)
at risk: elder and infants
normal range for sodium - ANSWER 135-145 mEg/L
normal range for potassium - ANSWER 3.5-5.0 mEq/L
normal range for calcium - ANSWER 9-10.5 mg/dl
normal range for magnesium - ANSWER 1.5-2.5 mEq/L
what are the s/s of hypokalemia - ANSWER abdominal pain, dysrhythmia,
muscle weakness, decreased reflexes, paralysis, urinary retention, increased
urine pH, confusion, and ECG changes
what are the nursing intervention for a patient with hypernatremia -
ANSWER encourage fluid intake, I&O, give water between tube feedings,
restrict sodium intake, and monitor temp
what are the s/s of hypocalcemia - ANSWER paresthesias, cramps/spasms,
weak pulse, decrease BP, + chvostek/trousseau sign, dysrhythmia, dyspnea,
, wheezing, difficulty swallowing, and cardiac failure
what are the s/s of hypermagnesemia - ANSWER hypotension,
sweating/flushing, nausea/vomiting, weakness, paralysis, respiratory
depression, and cardiac dysrhythmias
what electrolyte imbalance is common with renal failure - ANSWER
hyper/hypokalemia
what are the causes of respiratory acidosis - ANSWER slow shallow
respiration (hypoventilation), respiratory congestion or obstruction
what is the cause of respiratory alkalosis - ANSWER hyperventilation
(anxiety), high fever, or overdose of aspirin
what are the causes of metabolic alkalosis - ANSWER vomiting, excessive
antacid intake, extensive GI suction, and hypokalemia
what are the causes of metabolic acidosis - ANSWER sepsis, shock (poor
circulation), DKA, renal failure, hyperkalemia, and diarrhea
what are the nursing interventions for respiratory acidosis - ANSWER oxygen
administration, deep breathing treatments, incentive spirometer,
broncholdilators, and antibiotics
what are the nursing interventions for metabolic acidosis - ANSWER insulin
give with DKA, treating underlying causes, and administer IV sodium
bicarbonate
what are the nursing interventions for respiratory alkalosis - ANSWER
breathing through a brown bag and sedatives
what are complication associated with catherization - ANSWER CAUTI -
