NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
*This is a supplemental tool to help with your studies*
Name: Jessica Cox D#: 41103415
1. Describe what causes fluid volume deficit, and list the clinical manifestations,
nursing management, treatment, and education.
HYPOVOLEMIA - Shift of fluids from plasma into interstitial fluid.
Fluid Volume deficit is HYPOvolemia.
Causes? Fever, heatstroke, Diabetes insipidus, GI losses, hemorrhage, dehydration
Clinical Manifestations: Poor skin turgor, lethargy, thirst, dry mucous membranes,
decreased urine output/concentration, increased RR, orthostatic hypotension.
Nursing management/assessment: VS changes = decreased BP, Increased HR, increased
RR, flattened neck veins, thready pulse. Check skin turgor, skin for breakdown, daily
weights, I/O’s, LOC, oxygen administration, safe administration of blood.
Treatment: Increase fluids, Blood transfusion
Education: Educate patient of S/S of fluid volume deficit.
NANDA: Fluid imbalance, impaired cardiac output, acute confusion, potential
complication: hypovolemic shock
Client education- Good skin care, if orthostatic hypotension is present, teach to change
positions slowly, remind patient to drink
2. Describe what causes fluid volume excess, and list the clinical manifestations,
nursing management, treatment, and education.
Excess intake of fluids, abnormal retention of fluids, heart failure or renal failure, or a
shift of fluid from interstitial fluid into plasma fluid. Weight gain is the #1 manifestation.
Fluid Volume excess is HYPERvolemia.
Causes? Excessive fluid intake, abnormal retention of fluids (CHF or renal failure),
SIADH, Cushing’s’.
Clinical Manifestations: Increased BP, bounding pulse, edema, HA, polyuria,
crackles/dyspnea, weight increase
Nursing management/assessments: 24-hour I/O’s, assess cardio changes, respiratory
changes, LOC, PEERLA, daily weights, and skin turgor.
Treatment: Diet, fluid/sodium restriction, fluids, diuretics
Types of diuretics>>
1. Loop diuretics – Furosemide (Lasix)
2. Thiazides – Hydrochlorothiazide
3. Potassium sparing – Spiro lactone
4. Quinazoline - metolazone
Educations: Loop diuretics can cause the kidneys to increase flow of urine; this helps
reduce the amount of water in your body and lower your BP. Take medication in AM.
Thiazides reduce the amount of sodium and water in the body; they are the only type that
dilates the blood vessels, which also helps to lower BP. Potassium-sparing is used to
reduce the amount of water in the body; unlike the others, these do not cause your body
to lose K+. Do NOT in increase K+ intake in diet.
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
3. Describe the laboratory normal values, clinical manifestations, assessment priorities
(i.e. neuro, cardiac, cardiovascular, etc.) & nursing collaborative management of the
below electrolyte imbalances.
Clinical Clinical Assessment Nursing Nursing
Lab Values Manifestations priorities Management Education and
(Include diet) considerations
Hyponatremia Perform a Hypo- - Monitor daily
< 135 mEq/L Hypo- neurological Replacing fluid weight, I&O and VS
N/V, abdominal assessment. using isotonic
cramping, weight Severe sodium- Monitor sodium
gain, cold/clammy hyponatremia containing levels
skin, fatigue,
causes seizures, solutions. -
dyspnea, shortness of
breath, crackles, confusion and Encouraging oral Hyper-increase
preorbital edema, (+) coma (pg 278) intake. - Withhold fluids
JVD, restlessness, all diuretics. -
muscle weakness, Acute or more Hypo- fluid
low urine SG, HCT is Perform serious, small restrictions
Hypernatremia high, seizures/coma. neurological amounts of IV
>145 mEq/L assessment for hypertonic saline
hypernatremia. solution (3%
*Think Hypernatremia sodium chloride)
causes can restore the
Confusion* dehydration serum sodium
Hyper-
which alters the level.
Dry mucous
membrane, neck vein mental status and
is flat, dry skin, also causes Hyper - Treat
intense thirst, drowsiness, underlying cause
oliguria, dark urine, restlessness, -Primary water
orthostatic confusion, and deficit- replace
hypotension, lethargy to fluid orally or IV
tachycardia w/ seizures and with isotonic
thready pulse, coma. (pg 276)
tachypnea, hypoxia,
weight loss.
Hyperkalemia -Monitor acid -No potassium- Safety Alert -
>5.0 mEq/L Hypo- base balance b/c rich foods, No use Always dilute IV
Fatigue, Muscle too much K+ can of salt KCl and do not give
weakness, leg cause blood to supplements. in concentrated
cramps, Soft, flabby become acidic, amounts.
muscles, Monitor EKG
Paresthesia, with VS. - Never give KCl via
Hypokalemia decreased reflexes, - Monitor blood -Increase IV push or as a
<3.5 mEq/L Constipation, levels hourly. potassium-rich bolus. - Invert IV
nausea, paralytic (Can cause foods, administer bags containing KCl
*Think heart* ileus, Shallow alkalosis) potassium several times to
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
12 lead EKG for respirations, Weak, supplements, ensure even
irregular pulse, monitor EKG and distribution in the
Dx Hyperglycemia VS. bag. - Do not add
KCl to a hanging IV
Hyper- bag to prevent
Fatigue, irritability, giving a bolus dose.
Muscle weakness,
cramps, Loss of
muscle tone,
Paresthesia,
decreased reflexes,
Abdominal
cramping, diarrhea,
vomiting,
Confusion,
Irregular pulse,
Tetany
Hypercalcemia -Monitor food -Encourage -Educate PT on
>10.5 mg/dl Hypo- intake, I/O’s, ambulation, importance of
Weakness, fatigue, neuro assessment, reduce calcium mobility for GI and
Depression, VS, pain reaction, intakes, ROM.
irritability, monitor blood administer -Educate PT of
Hypocalcemia confusion, work diuretics to proper foods to
<8.4 mg/dl Hyperreflexia, (CBC/chemical increase excretion eat/avoid.
muscle cramps, ↓ panel) of calcium. -Educate PT on s/s
*Think bone* BP, Numbness and -Check for a -Increase calcium possible after
tingling in positive Chvostek intake, administer surgical procedure
extremities and & Trousseau’s IV calcium (24-48 hrs after).
region around sign. chloride or
mouth, Chvostek's gluconate,
sign, Trousseau's provide padded
sign, Laryngeal and side rails in case
bronchial spasms, PT has
Tetany, seizures, convulsions/seizu
Tachycardia res.
Hyper-
Lethargy,
weakness, fatigue,
Decreased memory,
Depressed reflexes,
↑ BP, Confusion,
psychosis,
Anorexia, nausea,
vomiting, Bone
pain, fractures,
Polyuria,
July 2021
*This is a supplemental tool to help with your studies*
Name: Jessica Cox D#: 41103415
1. Describe what causes fluid volume deficit, and list the clinical manifestations,
nursing management, treatment, and education.
HYPOVOLEMIA - Shift of fluids from plasma into interstitial fluid.
Fluid Volume deficit is HYPOvolemia.
Causes? Fever, heatstroke, Diabetes insipidus, GI losses, hemorrhage, dehydration
Clinical Manifestations: Poor skin turgor, lethargy, thirst, dry mucous membranes,
decreased urine output/concentration, increased RR, orthostatic hypotension.
Nursing management/assessment: VS changes = decreased BP, Increased HR, increased
RR, flattened neck veins, thready pulse. Check skin turgor, skin for breakdown, daily
weights, I/O’s, LOC, oxygen administration, safe administration of blood.
Treatment: Increase fluids, Blood transfusion
Education: Educate patient of S/S of fluid volume deficit.
NANDA: Fluid imbalance, impaired cardiac output, acute confusion, potential
complication: hypovolemic shock
Client education- Good skin care, if orthostatic hypotension is present, teach to change
positions slowly, remind patient to drink
2. Describe what causes fluid volume excess, and list the clinical manifestations,
nursing management, treatment, and education.
Excess intake of fluids, abnormal retention of fluids, heart failure or renal failure, or a
shift of fluid from interstitial fluid into plasma fluid. Weight gain is the #1 manifestation.
Fluid Volume excess is HYPERvolemia.
Causes? Excessive fluid intake, abnormal retention of fluids (CHF or renal failure),
SIADH, Cushing’s’.
Clinical Manifestations: Increased BP, bounding pulse, edema, HA, polyuria,
crackles/dyspnea, weight increase
Nursing management/assessments: 24-hour I/O’s, assess cardio changes, respiratory
changes, LOC, PEERLA, daily weights, and skin turgor.
Treatment: Diet, fluid/sodium restriction, fluids, diuretics
Types of diuretics>>
1. Loop diuretics – Furosemide (Lasix)
2. Thiazides – Hydrochlorothiazide
3. Potassium sparing – Spiro lactone
4. Quinazoline - metolazone
Educations: Loop diuretics can cause the kidneys to increase flow of urine; this helps
reduce the amount of water in your body and lower your BP. Take medication in AM.
Thiazides reduce the amount of sodium and water in the body; they are the only type that
dilates the blood vessels, which also helps to lower BP. Potassium-sparing is used to
reduce the amount of water in the body; unlike the others, these do not cause your body
to lose K+. Do NOT in increase K+ intake in diet.
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
3. Describe the laboratory normal values, clinical manifestations, assessment priorities
(i.e. neuro, cardiac, cardiovascular, etc.) & nursing collaborative management of the
below electrolyte imbalances.
Clinical Clinical Assessment Nursing Nursing
Lab Values Manifestations priorities Management Education and
(Include diet) considerations
Hyponatremia Perform a Hypo- - Monitor daily
< 135 mEq/L Hypo- neurological Replacing fluid weight, I&O and VS
N/V, abdominal assessment. using isotonic
cramping, weight Severe sodium- Monitor sodium
gain, cold/clammy hyponatremia containing levels
skin, fatigue,
causes seizures, solutions. -
dyspnea, shortness of
breath, crackles, confusion and Encouraging oral Hyper-increase
preorbital edema, (+) coma (pg 278) intake. - Withhold fluids
JVD, restlessness, all diuretics. -
muscle weakness, Acute or more Hypo- fluid
low urine SG, HCT is Perform serious, small restrictions
Hypernatremia high, seizures/coma. neurological amounts of IV
>145 mEq/L assessment for hypertonic saline
hypernatremia. solution (3%
*Think Hypernatremia sodium chloride)
causes can restore the
Confusion* dehydration serum sodium
Hyper-
which alters the level.
Dry mucous
membrane, neck vein mental status and
is flat, dry skin, also causes Hyper - Treat
intense thirst, drowsiness, underlying cause
oliguria, dark urine, restlessness, -Primary water
orthostatic confusion, and deficit- replace
hypotension, lethargy to fluid orally or IV
tachycardia w/ seizures and with isotonic
thready pulse, coma. (pg 276)
tachypnea, hypoxia,
weight loss.
Hyperkalemia -Monitor acid -No potassium- Safety Alert -
>5.0 mEq/L Hypo- base balance b/c rich foods, No use Always dilute IV
Fatigue, Muscle too much K+ can of salt KCl and do not give
weakness, leg cause blood to supplements. in concentrated
cramps, Soft, flabby become acidic, amounts.
muscles, Monitor EKG
Paresthesia, with VS. - Never give KCl via
Hypokalemia decreased reflexes, - Monitor blood -Increase IV push or as a
<3.5 mEq/L Constipation, levels hourly. potassium-rich bolus. - Invert IV
nausea, paralytic (Can cause foods, administer bags containing KCl
*Think heart* ileus, Shallow alkalosis) potassium several times to
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
12 lead EKG for respirations, Weak, supplements, ensure even
irregular pulse, monitor EKG and distribution in the
Dx Hyperglycemia VS. bag. - Do not add
KCl to a hanging IV
Hyper- bag to prevent
Fatigue, irritability, giving a bolus dose.
Muscle weakness,
cramps, Loss of
muscle tone,
Paresthesia,
decreased reflexes,
Abdominal
cramping, diarrhea,
vomiting,
Confusion,
Irregular pulse,
Tetany
Hypercalcemia -Monitor food -Encourage -Educate PT on
>10.5 mg/dl Hypo- intake, I/O’s, ambulation, importance of
Weakness, fatigue, neuro assessment, reduce calcium mobility for GI and
Depression, VS, pain reaction, intakes, ROM.
irritability, monitor blood administer -Educate PT of
Hypocalcemia confusion, work diuretics to proper foods to
<8.4 mg/dl Hyperreflexia, (CBC/chemical increase excretion eat/avoid.
muscle cramps, ↓ panel) of calcium. -Educate PT on s/s
*Think bone* BP, Numbness and -Check for a -Increase calcium possible after
tingling in positive Chvostek intake, administer surgical procedure
extremities and & Trousseau’s IV calcium (24-48 hrs after).
region around sign. chloride or
mouth, Chvostek's gluconate,
sign, Trousseau's provide padded
sign, Laryngeal and side rails in case
bronchial spasms, PT has
Tetany, seizures, convulsions/seizu
Tachycardia res.
Hyper-
Lethargy,
weakness, fatigue,
Decreased memory,
Depressed reflexes,
↑ BP, Confusion,
psychosis,
Anorexia, nausea,
vomiting, Bone
pain, fractures,
Polyuria,
July 2021
