NUR 313: NURSING CONCEPTS FOR ADULT HEALTH EXAM 1
QUESTIONS WITH COMPLETE SOLUTIONS
What are the causes of hypovolemia (ECF volume deficit)? - ANSWER-Abnormal
fluid loss (diarrhea, hemorrhage)
Inadequate intake
Plasma-to-interstitial fluid shift
What are the treatments for hypovolemia? - ANSWER-Fluid/electrolyte
replacement with IV solutions
Isotonic 0.9% NaCl
What should be included in the nursing assessment of a patient with
hypovolemia? - ANSWER-Skin assessment - moisture status, elasticity/turgor
Sclera and oral mucosa for dryness
Urine output
Daily weights
BP & pulse - watch for hypotension & reflex tachycardia
What are the causes of hypervolemia (ECF volume excess)? - ANSWER-Excess
fluid intake
Abnormal fluid retention
Plasma-to-interstital fluid shift
,What is the treatment for hypervolemia? - ANSWER-Remove fluid without
changing electrolyte composition
What should be included in the nursing assessment of a patient with
hypervolemia? - ANSWER-Labored breathing - fluid buildup in the lungs, crackles
HTN & tachycardia
Significant weight gain
Venous distention (especially jugular)
Diabetes mellitus
What are the nursing implementations for a patient with hypervolemia? -
ANSWER-I & O
Cardiovascular changes
Respiratory changes
Daily weights
Skin condition
Neurological function
What are the normal values of sodium? - ANSWER-135 - 145 mEq/L
What are the responsibilities of sodium? - ANSWER-ECF volume & concentration
(primary ECF determinant)
Generation & transmission of nerve impulses
,Acid-base balance
Kidneys are primary sodium balance regulator
What sodium values indicate hypernatremia? - ANSWER-Na+ > 145 mEq/L
What are the causes of hypernatremia? - ANSWER-Too little water
Too much sodium
Both
What are the manifestations of hypernatremia? - ANSWER-Thirst
Lethargy
Agitation
Seizures
Coma
Impaired level of consciousness
What are the nursing implementations for hypernatremia? - ANSWER-Treat
underlying cause
Diuretics
If oral fluids cannot be ingested, IV hypotonic solution (5% dextrose in water)
What sodium values indicate hyponatremia? - ANSWER-Na+ < 135 mEq/L
, What are the causes of hyponatremia? - ANSWER-Loss of sodium-containing
fluids
Water excess
What are the manifestations of hyponatremia? - ANSWER-Confusion
N/V
Seizures
Coma
What are the nursing implementations for hyponatremia? - ANSWER-Water
excess - fluid restriction
Severe symptoms (seizures) - IV hypertonic solution (3% NaCl)
Abnormal fluid loss - fluid replacement with sodium-containing solution
Vasopressins
What are the normal values for potassium? - ANSWER-3.5 - 5.0 mEq/L
What are the responsibilities of potassium? - ANSWER-Transmission &
conduction of nerve & muscle impulses
Cellular growth
Maintenance of cardiac rhythms
Acid-base balance
What potassium values indicate hyperkalemia? - ANSWER-K+ > 5.0 mEq/L
QUESTIONS WITH COMPLETE SOLUTIONS
What are the causes of hypovolemia (ECF volume deficit)? - ANSWER-Abnormal
fluid loss (diarrhea, hemorrhage)
Inadequate intake
Plasma-to-interstitial fluid shift
What are the treatments for hypovolemia? - ANSWER-Fluid/electrolyte
replacement with IV solutions
Isotonic 0.9% NaCl
What should be included in the nursing assessment of a patient with
hypovolemia? - ANSWER-Skin assessment - moisture status, elasticity/turgor
Sclera and oral mucosa for dryness
Urine output
Daily weights
BP & pulse - watch for hypotension & reflex tachycardia
What are the causes of hypervolemia (ECF volume excess)? - ANSWER-Excess
fluid intake
Abnormal fluid retention
Plasma-to-interstital fluid shift
,What is the treatment for hypervolemia? - ANSWER-Remove fluid without
changing electrolyte composition
What should be included in the nursing assessment of a patient with
hypervolemia? - ANSWER-Labored breathing - fluid buildup in the lungs, crackles
HTN & tachycardia
Significant weight gain
Venous distention (especially jugular)
Diabetes mellitus
What are the nursing implementations for a patient with hypervolemia? -
ANSWER-I & O
Cardiovascular changes
Respiratory changes
Daily weights
Skin condition
Neurological function
What are the normal values of sodium? - ANSWER-135 - 145 mEq/L
What are the responsibilities of sodium? - ANSWER-ECF volume & concentration
(primary ECF determinant)
Generation & transmission of nerve impulses
,Acid-base balance
Kidneys are primary sodium balance regulator
What sodium values indicate hypernatremia? - ANSWER-Na+ > 145 mEq/L
What are the causes of hypernatremia? - ANSWER-Too little water
Too much sodium
Both
What are the manifestations of hypernatremia? - ANSWER-Thirst
Lethargy
Agitation
Seizures
Coma
Impaired level of consciousness
What are the nursing implementations for hypernatremia? - ANSWER-Treat
underlying cause
Diuretics
If oral fluids cannot be ingested, IV hypotonic solution (5% dextrose in water)
What sodium values indicate hyponatremia? - ANSWER-Na+ < 135 mEq/L
, What are the causes of hyponatremia? - ANSWER-Loss of sodium-containing
fluids
Water excess
What are the manifestations of hyponatremia? - ANSWER-Confusion
N/V
Seizures
Coma
What are the nursing implementations for hyponatremia? - ANSWER-Water
excess - fluid restriction
Severe symptoms (seizures) - IV hypertonic solution (3% NaCl)
Abnormal fluid loss - fluid replacement with sodium-containing solution
Vasopressins
What are the normal values for potassium? - ANSWER-3.5 - 5.0 mEq/L
What are the responsibilities of potassium? - ANSWER-Transmission &
conduction of nerve & muscle impulses
Cellular growth
Maintenance of cardiac rhythms
Acid-base balance
What potassium values indicate hyperkalemia? - ANSWER-K+ > 5.0 mEq/L
