NUR 242 – MEDICAL-SURGICAL NURSING EXAM
2 GALEN COLLEGE OF NURSING QUESTIONS
AND VERIFIED ANSWERS WITH RATIONALES
GRADED A+ LATEST
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Terms in this set (87)
Causes of fluid overload •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 •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 •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 •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 •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 •Isotonic overhydration
•HF and pulmonary edema
•Seizure
•Coma
Fluid overload medications Furosemide
Mannitol
S/S of dehydration •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 •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 •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
2 GALEN COLLEGE OF NURSING QUESTIONS
AND VERIFIED ANSWERS WITH RATIONALES
GRADED A+ LATEST
Save
Terms in this set (87)
Causes of fluid overload •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 •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 •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 •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 •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 •Isotonic overhydration
•HF and pulmonary edema
•Seizure
•Coma
Fluid overload medications Furosemide
Mannitol
S/S of dehydration •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 •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 •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
