NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
Name:
Describe what causes fluid volume deficit, and list the clinical manifestations,
nursing management, treatment, and education.
Abnormal loss of body fluids via diarrhea, vomiting, hemorrhage, polyuria.
Inadequate fluid intake and a shift from plasma to interstitial fluid.
Can also be caused by overuse of diuretics, pancreatitis, burns and diabetes insipidus.
Manifestations: cold clammy skin, increased respiratory rate, weakness, dizziness,
confusion, lethargy, weight loss and dry mucous membranes.
Nursing interventions: oral rehydration (less severe) or isotonic (0.9%) sodium
chloride or lactated ringers (more severe). Blood is given if volume loss is due to blood
loss. (Pg. 274)
Describe what causes fluid volume excess (FVE), and list the clinical
manifestations, nursing management, treatment, and education.
Abnormal retention of fluids (heart/renal failure), shift of fluid from interstitial to plasma
fluid. Treated with diuretics/ fluid restriction or sodium restrictions, or
thoracentesis/paracentesis.
Manifestations: elevated BP, dyspnea, crackles, pulmonary edema, muscle spasms,
weight gain, s3 heart sound, peripheral edema,
Nursing intervention: monitor volume with I/O. Weigh patient daily record (vomit,
diarrhea, urine, extra sweat). Monitor labs. With FVE, patient will have decreased BUN,
Na, and Hct levels. Implement fall precautions and give IV fluids as ordered.
Education: encouraging oral fluids as appropriate, elevating edematous extremities,
encouraging position changes, and assisting with frequent oral care. (Pg. 274)
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 Mgmt. Nurse Education
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
Lab Values Manifestation priorities (Include diet) & Considerations
Sodium - Na 136- Hyper- High Hyper Primary water Hyper
145 m/Eq/L. Restlessness, confusion, VS - Monitor deficit Replace fluid Weigh patient.
agitation, thirst, dry hemodynamic PO/IV) with isotonic Monitor I/O.
Hypernatremia swollen tongue, status, Skin turgor. 0.9% NaCl. Avoid food high in
Inadequate water weakness, muscle Mental status. Na excess sodium.
intake. Excess cramps, weight loss, Monitor Pt. Na free IV fluid D5% Change position
water loss. Sodium lethargy, seizure, coma response 2 Diuretics 4 excretion. slowly
gain (IV fluids). _______________ therapy ______________
Diabetes, Cushing Labs: Serum Na, Hypo Report S&S of
syndrome Hypo- Low Hct, serum Fluid restriction hypernatremia.
_______________ Cold clammy skin, dry osmolality isotonic IV (NS) ______________
mucous membranes, ______________ Sparingly use
Hyponatremia SOB, irritable, confused, Hypo diuretics. Hypo
(pg. 276) elevated pulse, N/V/D, VS - Monitor Vasopressin - block Weigh patient (daily
GI loss - D/V Renal tremors, thready pulse. hemodynamic activity of ADH. - same time, clothes,
loss (Diuretics, ADH status. Lung Phenergan or Zofran scale, etc.)
insufficiency) sounds - crackles. for nausea. May Monitor I/O.
Skin loss (Burns & Assess mental need urinary Provide high sodium
Wound drainage) status. Initiate catheter foods.
Fever, Heatstroke seizure
precautions Report S&S of
hyponatremia.
Potassium - K+ Hyper - Confusion, Hyper- Hyper - Increase Hyper - Report high
3.5 - 5.0 mEq/L Muscle tetany, N/V/D VS - Monitor excretion K+. Check serum K+
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
Hyperkalemia cramps, numbness, hemodynamic (Kayexalate) regularly.
Renal failure. tingling, cardiac status. 12 lead loop/thiazide Diet: Avoid foods
Adrenal dysrhythmia. (Tall T ECG/EKG, diuretic, dialysis with K+ (Bananas,
insufficiency. waves, no P waves) Acid/base balance Mon. ECG potatoes, raisin,
Potassium sparing ventricular fib. cardiac (too much K+ (dysrhythmias). nuts, seeds, etc.
diuretics - arrest causes blood to Mon BG
Furosemide _______________ be acidic) (hypoglycemia) Report S&S of
ACE’s- lisinopril Hypo - Thready pulse, Give glucose hyperkalemia.
ARBs - losartan. decreased BP. Labs: CBC, fluid Cardiac - give Calc. ______________
_______________ Dysrhythmias, muscle and electrolyte, chloride or Calc. Hypo - Report signs
Hypokalemia weakness, lethargy, Glucose, Serum gluconate. of low K+. Have
NG tube suction, shallow respirations, K+ Mon. Serum K+ serum K+ checked.
V/D, Laxatives, weight loss. ______________ ______________ Diet: Eat foods high
Ileostomy drainage, Hypo Hypo - Replace K+ in K+. Take oral K+
Diuretics VS - Monitor PO/IV. Always dilute. supplement as
hemodynamic Never give IV push prescribed with full
status. or IV bolus. Infusion glass water. Do not
rate not more than crush or chew.
10mEq/L/hr.
****If Pt. on Report S&S of
Furosemide and hypokalemia.
Digitalis****
May have Dig.
Toxicity
(confusion,
lethargy, N/V,
July 2021
Name:
Describe what causes fluid volume deficit, and list the clinical manifestations,
nursing management, treatment, and education.
Abnormal loss of body fluids via diarrhea, vomiting, hemorrhage, polyuria.
Inadequate fluid intake and a shift from plasma to interstitial fluid.
Can also be caused by overuse of diuretics, pancreatitis, burns and diabetes insipidus.
Manifestations: cold clammy skin, increased respiratory rate, weakness, dizziness,
confusion, lethargy, weight loss and dry mucous membranes.
Nursing interventions: oral rehydration (less severe) or isotonic (0.9%) sodium
chloride or lactated ringers (more severe). Blood is given if volume loss is due to blood
loss. (Pg. 274)
Describe what causes fluid volume excess (FVE), and list the clinical
manifestations, nursing management, treatment, and education.
Abnormal retention of fluids (heart/renal failure), shift of fluid from interstitial to plasma
fluid. Treated with diuretics/ fluid restriction or sodium restrictions, or
thoracentesis/paracentesis.
Manifestations: elevated BP, dyspnea, crackles, pulmonary edema, muscle spasms,
weight gain, s3 heart sound, peripheral edema,
Nursing intervention: monitor volume with I/O. Weigh patient daily record (vomit,
diarrhea, urine, extra sweat). Monitor labs. With FVE, patient will have decreased BUN,
Na, and Hct levels. Implement fall precautions and give IV fluids as ordered.
Education: encouraging oral fluids as appropriate, elevating edematous extremities,
encouraging position changes, and assisting with frequent oral care. (Pg. 274)
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 Mgmt. Nurse Education
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
Lab Values Manifestation priorities (Include diet) & Considerations
Sodium - Na 136- Hyper- High Hyper Primary water Hyper
145 m/Eq/L. Restlessness, confusion, VS - Monitor deficit Replace fluid Weigh patient.
agitation, thirst, dry hemodynamic PO/IV) with isotonic Monitor I/O.
Hypernatremia swollen tongue, status, Skin turgor. 0.9% NaCl. Avoid food high in
Inadequate water weakness, muscle Mental status. Na excess sodium.
intake. Excess cramps, weight loss, Monitor Pt. Na free IV fluid D5% Change position
water loss. Sodium lethargy, seizure, coma response 2 Diuretics 4 excretion. slowly
gain (IV fluids). _______________ therapy ______________
Diabetes, Cushing Labs: Serum Na, Hypo Report S&S of
syndrome Hypo- Low Hct, serum Fluid restriction hypernatremia.
_______________ Cold clammy skin, dry osmolality isotonic IV (NS) ______________
mucous membranes, ______________ Sparingly use
Hyponatremia SOB, irritable, confused, Hypo diuretics. Hypo
(pg. 276) elevated pulse, N/V/D, VS - Monitor Vasopressin - block Weigh patient (daily
GI loss - D/V Renal tremors, thready pulse. hemodynamic activity of ADH. - same time, clothes,
loss (Diuretics, ADH status. Lung Phenergan or Zofran scale, etc.)
insufficiency) sounds - crackles. for nausea. May Monitor I/O.
Skin loss (Burns & Assess mental need urinary Provide high sodium
Wound drainage) status. Initiate catheter foods.
Fever, Heatstroke seizure
precautions Report S&S of
hyponatremia.
Potassium - K+ Hyper - Confusion, Hyper- Hyper - Increase Hyper - Report high
3.5 - 5.0 mEq/L Muscle tetany, N/V/D VS - Monitor excretion K+. Check serum K+
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
Hyperkalemia cramps, numbness, hemodynamic (Kayexalate) regularly.
Renal failure. tingling, cardiac status. 12 lead loop/thiazide Diet: Avoid foods
Adrenal dysrhythmia. (Tall T ECG/EKG, diuretic, dialysis with K+ (Bananas,
insufficiency. waves, no P waves) Acid/base balance Mon. ECG potatoes, raisin,
Potassium sparing ventricular fib. cardiac (too much K+ (dysrhythmias). nuts, seeds, etc.
diuretics - arrest causes blood to Mon BG
Furosemide _______________ be acidic) (hypoglycemia) Report S&S of
ACE’s- lisinopril Hypo - Thready pulse, Give glucose hyperkalemia.
ARBs - losartan. decreased BP. Labs: CBC, fluid Cardiac - give Calc. ______________
_______________ Dysrhythmias, muscle and electrolyte, chloride or Calc. Hypo - Report signs
Hypokalemia weakness, lethargy, Glucose, Serum gluconate. of low K+. Have
NG tube suction, shallow respirations, K+ Mon. Serum K+ serum K+ checked.
V/D, Laxatives, weight loss. ______________ ______________ Diet: Eat foods high
Ileostomy drainage, Hypo Hypo - Replace K+ in K+. Take oral K+
Diuretics VS - Monitor PO/IV. Always dilute. supplement as
hemodynamic Never give IV push prescribed with full
status. or IV bolus. Infusion glass water. Do not
rate not more than crush or chew.
10mEq/L/hr.
****If Pt. on Report S&S of
Furosemide and hypokalemia.
Digitalis****
May have Dig.
Toxicity
(confusion,
lethargy, N/V,
July 2021
