HURST REVIEW NCLEX RN FINAL
EXAM WTH 100% ACCURATE ANSWERS
hypervolemia is defined as? - too much fluid in the vascular space
what are the main causes of hypervolemia? - heart failure, renal failure, and anything
with lots of sodium (effervescent meds, canned/processed foods, IVF w/ sodium)
what two hormones regulate fluid volume in the body? - Aldosterone and ADH
What does aldosterone do and where is it secreted from? - causes the body to retain
water. secreted from the adrenal glands
what are diseases in which the body produces too much aldosterone (hormone that
retains water and sodium)? - cushing's disease (too many steroids)
Conn's disease
what does ADH do and where is it secreted from? - hormone that makes the body retain
water. secreted by the pituitary gland
what is a disease in which the body produces too much ADH? - SIADH
body retains fluid, extreme thirst, can throw patients into Fluid Volume Excess.
Tx: fluid restriction and Desmopressin to inhibit release of ADh
what are S&S of fluid volume overload? - JVD, peripheral edema, crackles/wet lung,
ascites, increased CVP, bounding pulses, fast weight gain
what is the treatment for fluid volume excess? - I/O and daily weights
diuretic therapy
sodium/fluid restriction
what are the causes of hypovolemia? - fluid loss from anywhere
third spacing (fluid in a place that does no good) ie. ascites
,what are s&s of hypovolemia? - weak and thready pulse
weight decrease
decreased Urinary output
tachycardia
what are some examples of isotonic solutions and what are they used for? - NS, LR,
D5W
replacement of lost fluids from n&v, burns, sweating, and trauma
what type of patient does not need to receive an isotonic solution? - pts w/
hypertension, cardiac disease, or renal failure
what are the causes of hypermagnesemia? - renal failure
antacid use
what is the antidote to magnesium - calcium gluconate
what are the causes of hypercalcemia? - hyperparathyroidism
thiazides
immobilization
what are signs and symptoms of hypermagnesemia and hypercalcemia? - decrease
DTRs
weak/flaccid muscle tone
decreased LOC
decreased HR and RR
what are s&s of hypomagnesemia and hypocalcemia? - rigid muscle tone
increased DTR
positive Chvostek's sign (tap cheek)
positive Trousseau's (pump up BP cuff)
,what are causes and s&s of hypernatremia? - dehydration
heat stroke
diabetes insipidus
s&s
dry mouth
swollen tongue
neuro changes
what are causes and s&s of hyperkalemia? - kidney trouble
spironalactone
s&s
twitching
muscle weakness
flaccid paralysis
what is a short term fix for hyperkalemia? - glucose and insulin
kayexalate
what is the long term treatment for hyperkalemia and kidney failure? - dialysis
never give ______________via IVP and always remind the patients that it will burn
during administration - potassium
where do most burns occur? - at home
what is the rule of nines? - quick way to determine how much of the skin's surface has
been burned
anytime a burn occurs on the face, neck, or chest, the priority is........? - airway
maintenance
in burn patients, how is the burning process stopped? - cool water (NOT COLD) for no
more than 10 minutes
blankets to hold in body heat and keep out germs
removal of any jewelry and clothing
burn patients need how many IVs and what type of IV fluids? - at least 2 large bore IVs
, crystalloids (LR) and colloids (albumin)
how is fluid resuscitation in burns determined? - total body surface area burned x weight
in kilograms
divide in half
first half in the first 8hrs
remaining amount over the next 16hrs
in burn patients, what is the nurse's priority? - hypoxia
what is the most accurate determination of fluid volume status in burn patients? - urine
output
why is albumin given to burn patients? - it increases vascular volume, kidney perfusion,
BP, and CO
what electrolyte imbalance is the main concern in burn patients? - hyperkalemia
to prevent contractures in burn patients, what should the nurse do? - if burned on the
hand, the nurse should wrap each finger separately and use splints
for burns on the neck/face, do not place pillows under the head. extend the neck (head
is back) to prevent chin-chest contractures
what is the number one intervention in chemical burns? - flushing for 15-30 min with
cool water or sterile saline
what is the number one concern with electrical burned patients? - internal wounds and
cardiac dysrhythmias
what is the number one preventable cause of cancer? - tobacco
what is primary prevention? - Health promotion and illness prevention
what is secondary prevention? - This is using screenings to pick up on diseases early,
when there is a greater chance for cure or control
how often should women over 40 receive a breast exam? - yearly
how often should women 18-39 receive breast exams? - every 3 years
how often should women receive mammograms after age 40? - annually
EXAM WTH 100% ACCURATE ANSWERS
hypervolemia is defined as? - too much fluid in the vascular space
what are the main causes of hypervolemia? - heart failure, renal failure, and anything
with lots of sodium (effervescent meds, canned/processed foods, IVF w/ sodium)
what two hormones regulate fluid volume in the body? - Aldosterone and ADH
What does aldosterone do and where is it secreted from? - causes the body to retain
water. secreted from the adrenal glands
what are diseases in which the body produces too much aldosterone (hormone that
retains water and sodium)? - cushing's disease (too many steroids)
Conn's disease
what does ADH do and where is it secreted from? - hormone that makes the body retain
water. secreted by the pituitary gland
what is a disease in which the body produces too much ADH? - SIADH
body retains fluid, extreme thirst, can throw patients into Fluid Volume Excess.
Tx: fluid restriction and Desmopressin to inhibit release of ADh
what are S&S of fluid volume overload? - JVD, peripheral edema, crackles/wet lung,
ascites, increased CVP, bounding pulses, fast weight gain
what is the treatment for fluid volume excess? - I/O and daily weights
diuretic therapy
sodium/fluid restriction
what are the causes of hypovolemia? - fluid loss from anywhere
third spacing (fluid in a place that does no good) ie. ascites
,what are s&s of hypovolemia? - weak and thready pulse
weight decrease
decreased Urinary output
tachycardia
what are some examples of isotonic solutions and what are they used for? - NS, LR,
D5W
replacement of lost fluids from n&v, burns, sweating, and trauma
what type of patient does not need to receive an isotonic solution? - pts w/
hypertension, cardiac disease, or renal failure
what are the causes of hypermagnesemia? - renal failure
antacid use
what is the antidote to magnesium - calcium gluconate
what are the causes of hypercalcemia? - hyperparathyroidism
thiazides
immobilization
what are signs and symptoms of hypermagnesemia and hypercalcemia? - decrease
DTRs
weak/flaccid muscle tone
decreased LOC
decreased HR and RR
what are s&s of hypomagnesemia and hypocalcemia? - rigid muscle tone
increased DTR
positive Chvostek's sign (tap cheek)
positive Trousseau's (pump up BP cuff)
,what are causes and s&s of hypernatremia? - dehydration
heat stroke
diabetes insipidus
s&s
dry mouth
swollen tongue
neuro changes
what are causes and s&s of hyperkalemia? - kidney trouble
spironalactone
s&s
twitching
muscle weakness
flaccid paralysis
what is a short term fix for hyperkalemia? - glucose and insulin
kayexalate
what is the long term treatment for hyperkalemia and kidney failure? - dialysis
never give ______________via IVP and always remind the patients that it will burn
during administration - potassium
where do most burns occur? - at home
what is the rule of nines? - quick way to determine how much of the skin's surface has
been burned
anytime a burn occurs on the face, neck, or chest, the priority is........? - airway
maintenance
in burn patients, how is the burning process stopped? - cool water (NOT COLD) for no
more than 10 minutes
blankets to hold in body heat and keep out germs
removal of any jewelry and clothing
burn patients need how many IVs and what type of IV fluids? - at least 2 large bore IVs
, crystalloids (LR) and colloids (albumin)
how is fluid resuscitation in burns determined? - total body surface area burned x weight
in kilograms
divide in half
first half in the first 8hrs
remaining amount over the next 16hrs
in burn patients, what is the nurse's priority? - hypoxia
what is the most accurate determination of fluid volume status in burn patients? - urine
output
why is albumin given to burn patients? - it increases vascular volume, kidney perfusion,
BP, and CO
what electrolyte imbalance is the main concern in burn patients? - hyperkalemia
to prevent contractures in burn patients, what should the nurse do? - if burned on the
hand, the nurse should wrap each finger separately and use splints
for burns on the neck/face, do not place pillows under the head. extend the neck (head
is back) to prevent chin-chest contractures
what is the number one intervention in chemical burns? - flushing for 15-30 min with
cool water or sterile saline
what is the number one concern with electrical burned patients? - internal wounds and
cardiac dysrhythmias
what is the number one preventable cause of cancer? - tobacco
what is primary prevention? - Health promotion and illness prevention
what is secondary prevention? - This is using screenings to pick up on diseases early,
when there is a greater chance for cure or control
how often should women over 40 receive a breast exam? - yearly
how often should women 18-39 receive breast exams? - every 3 years
how often should women receive mammograms after age 40? - annually
