NUR1023C FINAL EXAM – Accurate Solutions For
Every Question
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Terms in this set (264)
Fluid Volume Deficit Hypovolemia
Fluid Volume Excess Hypervolemia
FVD S/Sx Dry mucous membranes
Tachycardia
Decrease Weight
Oliguria
Peripheral pulses decreased
Decreased cognition
FVD Labs (Increasing) Increase hematocrit
Increase serum osmolality
Increase BUN (blood urea nitrogen)
Increase sodium
Increase glucose
Increase specific gravity
FVD Interventions Fluids: PO, IV
Level of consciousness
Urine output <30mL per hour; report
Intake and output
Document vital signs, weight
Safety-shock position
Discharge Teaching:
Take adequate fluid intake
Monitor urine output
Take daily weight
,FVE S/Sx (Increasing) Increase pulse
Increase blood pressure
Increase confusion
Increase edema
Increase swelling neck
Increase weight
Increase ascites
Increase crackles in lungs
Increase respirations
FVE Labs (Decreasing) Decrease hematocrit
Decrease serum osmolality
Decrease BUN (blood urea nitrogen)
Decrease sodium
Decrease glucose
Decrease urine specific gravity
FVE Interventions (RESTRICTDD) Reduce IV flow rate
Evaluate breath sounds and ABGs (arterial blood
gas)
Semi-Fowlers/high Fowlers, O2
Treat with O2 and diuretics
Reduce fluid and sodium intake
I &O and daily weight
Circulation, color, and presence of edema
Turn and position Q2hrs
Discharge Teaching:
Discuss OTC with health care provider
Low levels of protein in the blood can cause edema, or swelling, because proteins help
prevent fluid from leaking out of blood vessels.
,Hyponatremia S/Sx (Decreasing) Decrease LOC (level of consciousness)
Decrease muscle strength
Decrease DTR (deep tendon reflex)
Decrease output
Decrease urine output
Decrease volume=fast HR
Decrease blood pressure
Decrease weight
Decrease sodium intake
Hyponatremia Interventions Seizure precautions
(SODIUM) Occurs in Addison, renal disease, NPO, vomiting,
diarrhea, burns
Daily weight; foods high in Na (milk, cheese)
If retaining fluids, restrict fluids
Understand the cause: use hypertonic fluids if severe,
isotonic is moderate
Monitor vital signs, I&O, neuro assessment
Hypernatremia S/Sx (DRIED) Dry mucous membranes
Red, flushed skin
Increased temperature, I&O
Elevated HR
Decreased weight, blood pressure, urine output
Hypernatremia Interventions Restrict fluid intake
(RESTRICT) Evaluate cerebral changes
Strict intake and output
The blood pressure is elevated (fluid volume excess);
the blood pressure is low (fluid deficit)
Review origin of hypernatremia
If fluid deficit, give hypotonic IV fluids. Encourage
fluid intake, discourage sodium intake
Check daily weights, neuro assessments
The excess fluid may be removed by diuretics
, Hypokalemia S/Sx (CRAMPS) Complications with GI losses
Reflexes and respirations decrease
Arrythmias
Muscle cramps
Pulse irregular and weak, decrease B/P
Serum K+ <3.5 mEq/L
Hypokalemia Interventions Potatoes, avocados, bananas, broccoli
(POTASSIUM) Oral potassium
T wave depression (monitor)
Arrythmia-monitor
Shallow ineffective respirations (monitor)
Sounds of breathing diminished (monitor)
IV supplements is never a IV push
Urine output and intake (monitor)
Muscle cramping, muscle weakness,
Hyperkalemia S/Sx (DEATH) Dysrhythmias
ECG changes
Abdominal cramping, diarrhea
The muscle twitch
Hypotension; irritability/restlessness
Hyperkalemia Interventions (STOPS) Stop IV potassium infusion
Tall T waves, widened QRS (Monitor ECG)
Orders: Kayexalate or dextrose with insulin
Provide potassium restricted foods
Salt substitutes not allowed
Hypocalcemia S/Sx (TWITCH) Trousseau's sign; tingling, numbness
Watch for dysrhythmias
Increase in bowel sounds; diarrhea
Tetany, twitching, tingling, seizures
Chvostek's sign
Hypotension, hyperactive DTR
Hypocalcemia Interventions (SAFE) Seizure precautions
Administer calcium supplements
Foods high in calcium (dairy, greens) educate patient
Emergency equipment on standby; monitor
Every Question
Save
Terms in this set (264)
Fluid Volume Deficit Hypovolemia
Fluid Volume Excess Hypervolemia
FVD S/Sx Dry mucous membranes
Tachycardia
Decrease Weight
Oliguria
Peripheral pulses decreased
Decreased cognition
FVD Labs (Increasing) Increase hematocrit
Increase serum osmolality
Increase BUN (blood urea nitrogen)
Increase sodium
Increase glucose
Increase specific gravity
FVD Interventions Fluids: PO, IV
Level of consciousness
Urine output <30mL per hour; report
Intake and output
Document vital signs, weight
Safety-shock position
Discharge Teaching:
Take adequate fluid intake
Monitor urine output
Take daily weight
,FVE S/Sx (Increasing) Increase pulse
Increase blood pressure
Increase confusion
Increase edema
Increase swelling neck
Increase weight
Increase ascites
Increase crackles in lungs
Increase respirations
FVE Labs (Decreasing) Decrease hematocrit
Decrease serum osmolality
Decrease BUN (blood urea nitrogen)
Decrease sodium
Decrease glucose
Decrease urine specific gravity
FVE Interventions (RESTRICTDD) Reduce IV flow rate
Evaluate breath sounds and ABGs (arterial blood
gas)
Semi-Fowlers/high Fowlers, O2
Treat with O2 and diuretics
Reduce fluid and sodium intake
I &O and daily weight
Circulation, color, and presence of edema
Turn and position Q2hrs
Discharge Teaching:
Discuss OTC with health care provider
Low levels of protein in the blood can cause edema, or swelling, because proteins help
prevent fluid from leaking out of blood vessels.
,Hyponatremia S/Sx (Decreasing) Decrease LOC (level of consciousness)
Decrease muscle strength
Decrease DTR (deep tendon reflex)
Decrease output
Decrease urine output
Decrease volume=fast HR
Decrease blood pressure
Decrease weight
Decrease sodium intake
Hyponatremia Interventions Seizure precautions
(SODIUM) Occurs in Addison, renal disease, NPO, vomiting,
diarrhea, burns
Daily weight; foods high in Na (milk, cheese)
If retaining fluids, restrict fluids
Understand the cause: use hypertonic fluids if severe,
isotonic is moderate
Monitor vital signs, I&O, neuro assessment
Hypernatremia S/Sx (DRIED) Dry mucous membranes
Red, flushed skin
Increased temperature, I&O
Elevated HR
Decreased weight, blood pressure, urine output
Hypernatremia Interventions Restrict fluid intake
(RESTRICT) Evaluate cerebral changes
Strict intake and output
The blood pressure is elevated (fluid volume excess);
the blood pressure is low (fluid deficit)
Review origin of hypernatremia
If fluid deficit, give hypotonic IV fluids. Encourage
fluid intake, discourage sodium intake
Check daily weights, neuro assessments
The excess fluid may be removed by diuretics
, Hypokalemia S/Sx (CRAMPS) Complications with GI losses
Reflexes and respirations decrease
Arrythmias
Muscle cramps
Pulse irregular and weak, decrease B/P
Serum K+ <3.5 mEq/L
Hypokalemia Interventions Potatoes, avocados, bananas, broccoli
(POTASSIUM) Oral potassium
T wave depression (monitor)
Arrythmia-monitor
Shallow ineffective respirations (monitor)
Sounds of breathing diminished (monitor)
IV supplements is never a IV push
Urine output and intake (monitor)
Muscle cramping, muscle weakness,
Hyperkalemia S/Sx (DEATH) Dysrhythmias
ECG changes
Abdominal cramping, diarrhea
The muscle twitch
Hypotension; irritability/restlessness
Hyperkalemia Interventions (STOPS) Stop IV potassium infusion
Tall T waves, widened QRS (Monitor ECG)
Orders: Kayexalate or dextrose with insulin
Provide potassium restricted foods
Salt substitutes not allowed
Hypocalcemia S/Sx (TWITCH) Trousseau's sign; tingling, numbness
Watch for dysrhythmias
Increase in bowel sounds; diarrhea
Tetany, twitching, tingling, seizures
Chvostek's sign
Hypotension, hyperactive DTR
Hypocalcemia Interventions (SAFE) Seizure precautions
Administer calcium supplements
Foods high in calcium (dairy, greens) educate patient
Emergency equipment on standby; monitor
