Exam 1 NR 324 Adult Health 1
What age group has the highest percentage of water content? -Correct Answer=
Preterm / Neonates
Two fluid compartments in the body -Correct Answer= Intracellular space (inside cells)
located in the ICF
Extracellular space (outside cells) located in the ECF
ICF makes up what percent of total body weight? -Correct Answer= 40%
What are the two main compartments containing ECF? What other compartments are
there? -Correct Answer= Interstitial fluid (fluid in the spaces between cells)
Intravascular fluid (plasma)
Other compartments include lymph and transcellular fluids
Transcellular fluid includes -Correct Answer= Cerebrospinal fluid, fluid in the
gastrointestinal tract, and joint spaces as well as pleural, peritoneal, intraocular, and
pericardial fluid.
1L of water = _____ lb. -Correct Answer= 2.2 lb (1kg)
The concentrations of electrolytes in body fluids is expressed in _________ -Correct
Answer= milliequivalents (mEq) per Liter
What are the main Ions found in the ECF and ICF -Correct Answer= ECF cation-
sodium, with small amounts of potassium, calcium, and magnesium
ECF anion- chloride, with small amounts of bicarbonate, sulfate, and phosphate anions.
ICF cation- potassium, with small amounts of magnesium and sodium
ICF anion- phosphate, with some protein and a small amount of bicarbonate.
Hypovolemia (ECF volume deficit) -Correct Answer= abnormal loss of normal body
fluids, (D/V, hemorrhage, polyuria) inadequate intake, or plasma-to-interstitial fluid shift
Fluid volume deficit
Assessment- Causes-Treatment-Client education -Correct Answer= Assessment-
Restlessness, drowsiness, lethargy, confusion
• Thirst, dry mucous membranes
• Cold clammy skin
• Decreased skin turgor, ↓ capillary refill
• Postural hypotension, ↑ pulse, ↓ CVP
• ↓ Urine output, concentrated urine
• ↑ Respiratory rate
• Weakness, dizziness
,• Weight loss
• Seizures, coma
Causes- • ↑ Insensible water loss or perspiration (high fever, heatstroke)
• Diabetes insipidus
• Osmotic diuresis
• Hemorrhage
• GI losses: vomiting, NG suction, diarrhea, fistula drainage
• Overuse of diuretics
• Inadequate fluid intake
• Third-space fluid shifts: burns, pancreatitis
Treatment- replace water and electrolytes with balanced IV solutions
Client education- Good skin care, if orthostatic hypotension is present, teach to change
positions slowly, remind patient to drink
Hypervolemia (ECF volume excess) -Correct Answer= Excessive intake of fluids,
abnormal retention of fluids (HF or renal failure), or interstitial-to-plasma fluid shift
Fluid volume excess
Assessment- Causes-Treatment-Client education -Correct Answer= Assessment- •
Headache, confusion, lethargy
• Peripheral edema
• Jugular venous distention
• S3 heart sound
• Bounding pulse, ↑ BP, ↑ CVP
• Polyuria (with normal renal function)
• Dyspnea, crackles, pulmonary edema
• Muscle spasms
• Weight gain
• Seizures, coma
Causes- • Excessive isotonic or hypotonic IV fluids
• Heart failure
• Renal failure
• Primary polydipsia
• SIADH
• Cushing syndrome
• Long-term use of corticosteroids
Treatment-Remove fluid without changing electrolyte composition or osmolality of ECF
Client education- elevate edematous extremities
Nutrition related to potassium -Correct Answer= Diet is the source
-Fruit, dried fruits and vegetables
-Many salt substitutes contain substantial K+
Nutrition related to sodium -Correct Answer= -Daily intake far exceeds bodys daily
requirments
-Glucose promotes sodium and water absorption
,Hypertonic solutions -Correct Answer= initially raises the osmolality of ECF and
expands it
-higher osmotic pressure draws water out of the cells into the ECF
-Useful in treatment of hyponatremia and trauma patients with head injuries
Isotonic solutions -Correct Answer= has a similar concentration of water and electrolytes
to plasma, with an osmolality of 250 to 375 mOsm/L
-administering an isotonic solution expands only ECF and the fluid does not move into
cells
-the ideal fluid replacement for patients with ECF volume deficits
Hypotonic solutions -Correct Answer= solution has more water than electrolytes, with an
osmolality of less than 250 mOsm/kg.
-Infusing a hypotonic solution dilutes ECf
-good for treating patients with hypernatremia
As a nurse it is important to remember what administration guidelines when
administering IV KCL? -Correct Answer= • IV KCl must always be diluted and never
given in concentrated amounts.
• Never give KCl via IV push or as a bolus.
• Invert IV bags containing KCl several times to ensure even distribution in the bag.
• Do not add KCl to a hanging IV bag to prevent giving a bolus dose.
Hypernatremia -Correct Answer= Occurs when either too much water is lost or not
enough water intake, or too much salt is taken in
What S/S should the nurse look for when a patient is experiencing hypernatremia with
decreased, normal and increased ECF volume? -Correct Answer= Hypernatremia with
decreased ECF volume: • Restlessness, agitation, lethargy, seizures, coma
• Intense thirst, dry swollen tongue, sticky mucous membranes
• Postural hypotension, ↓ CVP, weight loss, ↑ pulse
• Weakness, muscle cramps
Hypernatremia with normal or increased ECF volume: • Restlessness, agitation,
twitching, seizures, coma
• Intense thirst, flushed skin
• Weight gain, peripheral and pulmonary edema, ↑ BP, ↑ CVP
Sodium plays a key role in the body by... -Correct Answer= Transmitting nerve impulses
Hyponatremia -Correct Answer= Occurs when the body loses more sodium than water
and there is a low level of sodium in the blood or when too much water is taken in or
retained or when there is organ failure
Hyperkalemia -Correct Answer= Occurs when potassium levels in your blood are higher
than normal
, -Excess K+ intake
-Shift of K+ out of cells
-Failure to eliminate K+
Potassium is crucial for __________ and ____________ function within the body?
-Correct Answer= Neuromuscular and cardiac function
What S/S should the nurse look for when a patient is experiencing hyperkalemia?
-Correct Answer= • Fatigue, irritability
• Muscle weakness, cramps
• Loss of muscle tone
• Paresthesias, decreased reflexes
• Abdominal cramping, diarrhea, vomiting
• Confusion
• Irregular pulse
• Tetany
What S/S should the nurse look for when a patient is experiencing hyponatremia with
decreased, normal and increased ECF volume? -Correct Answer= Hyponatremia with
decreased ECF volume: • Irritability, apprehension, confusion, dizziness, personality
changes, tremors, seizures, coma
• Dry mucous membranes
• Postural hypotension, ↓ CVP, ↓ jugular venous filling, ↑ pulse, thready pulse
• Cold and clammy skin
Hyponatremia with normal or increased ECF volume: • Headache, apathy, confusion,
muscle spasms, seizures, coma
• Nausea, vomiting, diarrhea, abdominal cramps
• Weight gain, ↑ BP, ↑ CVP
Hypokalemia -Correct Answer= Occurs when potassium levels in your blood are lower
than normal
-K+ loss
-Shift of K+ into cells
-Lack of K+ intake
What S/S should the nurse look for when a patient is experiencing hypokalemia?
-Correct Answer= • Fatigue
• Muscle weakness, leg cramps
• Soft, flabby muscles
• Paresthesias, decreased reflexes
• Constipation, nausea, paralytic ileus
• Shallow respirations
• Weak, irregular pulse
• Hyperglycemia
What age group has the highest percentage of water content? -Correct Answer=
Preterm / Neonates
Two fluid compartments in the body -Correct Answer= Intracellular space (inside cells)
located in the ICF
Extracellular space (outside cells) located in the ECF
ICF makes up what percent of total body weight? -Correct Answer= 40%
What are the two main compartments containing ECF? What other compartments are
there? -Correct Answer= Interstitial fluid (fluid in the spaces between cells)
Intravascular fluid (plasma)
Other compartments include lymph and transcellular fluids
Transcellular fluid includes -Correct Answer= Cerebrospinal fluid, fluid in the
gastrointestinal tract, and joint spaces as well as pleural, peritoneal, intraocular, and
pericardial fluid.
1L of water = _____ lb. -Correct Answer= 2.2 lb (1kg)
The concentrations of electrolytes in body fluids is expressed in _________ -Correct
Answer= milliequivalents (mEq) per Liter
What are the main Ions found in the ECF and ICF -Correct Answer= ECF cation-
sodium, with small amounts of potassium, calcium, and magnesium
ECF anion- chloride, with small amounts of bicarbonate, sulfate, and phosphate anions.
ICF cation- potassium, with small amounts of magnesium and sodium
ICF anion- phosphate, with some protein and a small amount of bicarbonate.
Hypovolemia (ECF volume deficit) -Correct Answer= abnormal loss of normal body
fluids, (D/V, hemorrhage, polyuria) inadequate intake, or plasma-to-interstitial fluid shift
Fluid volume deficit
Assessment- Causes-Treatment-Client education -Correct Answer= Assessment-
Restlessness, drowsiness, lethargy, confusion
• Thirst, dry mucous membranes
• Cold clammy skin
• Decreased skin turgor, ↓ capillary refill
• Postural hypotension, ↑ pulse, ↓ CVP
• ↓ Urine output, concentrated urine
• ↑ Respiratory rate
• Weakness, dizziness
,• Weight loss
• Seizures, coma
Causes- • ↑ Insensible water loss or perspiration (high fever, heatstroke)
• Diabetes insipidus
• Osmotic diuresis
• Hemorrhage
• GI losses: vomiting, NG suction, diarrhea, fistula drainage
• Overuse of diuretics
• Inadequate fluid intake
• Third-space fluid shifts: burns, pancreatitis
Treatment- replace water and electrolytes with balanced IV solutions
Client education- Good skin care, if orthostatic hypotension is present, teach to change
positions slowly, remind patient to drink
Hypervolemia (ECF volume excess) -Correct Answer= Excessive intake of fluids,
abnormal retention of fluids (HF or renal failure), or interstitial-to-plasma fluid shift
Fluid volume excess
Assessment- Causes-Treatment-Client education -Correct Answer= Assessment- •
Headache, confusion, lethargy
• Peripheral edema
• Jugular venous distention
• S3 heart sound
• Bounding pulse, ↑ BP, ↑ CVP
• Polyuria (with normal renal function)
• Dyspnea, crackles, pulmonary edema
• Muscle spasms
• Weight gain
• Seizures, coma
Causes- • Excessive isotonic or hypotonic IV fluids
• Heart failure
• Renal failure
• Primary polydipsia
• SIADH
• Cushing syndrome
• Long-term use of corticosteroids
Treatment-Remove fluid without changing electrolyte composition or osmolality of ECF
Client education- elevate edematous extremities
Nutrition related to potassium -Correct Answer= Diet is the source
-Fruit, dried fruits and vegetables
-Many salt substitutes contain substantial K+
Nutrition related to sodium -Correct Answer= -Daily intake far exceeds bodys daily
requirments
-Glucose promotes sodium and water absorption
,Hypertonic solutions -Correct Answer= initially raises the osmolality of ECF and
expands it
-higher osmotic pressure draws water out of the cells into the ECF
-Useful in treatment of hyponatremia and trauma patients with head injuries
Isotonic solutions -Correct Answer= has a similar concentration of water and electrolytes
to plasma, with an osmolality of 250 to 375 mOsm/L
-administering an isotonic solution expands only ECF and the fluid does not move into
cells
-the ideal fluid replacement for patients with ECF volume deficits
Hypotonic solutions -Correct Answer= solution has more water than electrolytes, with an
osmolality of less than 250 mOsm/kg.
-Infusing a hypotonic solution dilutes ECf
-good for treating patients with hypernatremia
As a nurse it is important to remember what administration guidelines when
administering IV KCL? -Correct Answer= • IV KCl must always be diluted and never
given in concentrated amounts.
• Never give KCl via IV push or as a bolus.
• Invert IV bags containing KCl several times to ensure even distribution in the bag.
• Do not add KCl to a hanging IV bag to prevent giving a bolus dose.
Hypernatremia -Correct Answer= Occurs when either too much water is lost or not
enough water intake, or too much salt is taken in
What S/S should the nurse look for when a patient is experiencing hypernatremia with
decreased, normal and increased ECF volume? -Correct Answer= Hypernatremia with
decreased ECF volume: • Restlessness, agitation, lethargy, seizures, coma
• Intense thirst, dry swollen tongue, sticky mucous membranes
• Postural hypotension, ↓ CVP, weight loss, ↑ pulse
• Weakness, muscle cramps
Hypernatremia with normal or increased ECF volume: • Restlessness, agitation,
twitching, seizures, coma
• Intense thirst, flushed skin
• Weight gain, peripheral and pulmonary edema, ↑ BP, ↑ CVP
Sodium plays a key role in the body by... -Correct Answer= Transmitting nerve impulses
Hyponatremia -Correct Answer= Occurs when the body loses more sodium than water
and there is a low level of sodium in the blood or when too much water is taken in or
retained or when there is organ failure
Hyperkalemia -Correct Answer= Occurs when potassium levels in your blood are higher
than normal
, -Excess K+ intake
-Shift of K+ out of cells
-Failure to eliminate K+
Potassium is crucial for __________ and ____________ function within the body?
-Correct Answer= Neuromuscular and cardiac function
What S/S should the nurse look for when a patient is experiencing hyperkalemia?
-Correct Answer= • Fatigue, irritability
• Muscle weakness, cramps
• Loss of muscle tone
• Paresthesias, decreased reflexes
• Abdominal cramping, diarrhea, vomiting
• Confusion
• Irregular pulse
• Tetany
What S/S should the nurse look for when a patient is experiencing hyponatremia with
decreased, normal and increased ECF volume? -Correct Answer= Hyponatremia with
decreased ECF volume: • Irritability, apprehension, confusion, dizziness, personality
changes, tremors, seizures, coma
• Dry mucous membranes
• Postural hypotension, ↓ CVP, ↓ jugular venous filling, ↑ pulse, thready pulse
• Cold and clammy skin
Hyponatremia with normal or increased ECF volume: • Headache, apathy, confusion,
muscle spasms, seizures, coma
• Nausea, vomiting, diarrhea, abdominal cramps
• Weight gain, ↑ BP, ↑ CVP
Hypokalemia -Correct Answer= Occurs when potassium levels in your blood are lower
than normal
-K+ loss
-Shift of K+ into cells
-Lack of K+ intake
What S/S should the nurse look for when a patient is experiencing hypokalemia?
-Correct Answer= • Fatigue
• Muscle weakness, leg cramps
• Soft, flabby muscles
• Paresthesias, decreased reflexes
• Constipation, nausea, paralytic ileus
• Shallow respirations
• Weak, irregular pulse
• Hyperglycemia
