NUR242 Exam 2 Galen NEWEST 2025 COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+||BRAND
NEW VERSION!!
Assessment for fluid overload - CORRECT ANSWER- •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 - CORRECT ANSWER- •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 - CORRECT ANSWER- •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 - CORRECT ANSWER- •Isotonic overhydration
•HF and pulmonary edema
•Seizure
•Coma
Causes of fluid overload - CORRECT ANSWER- •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 - CORRECT ANSWER- •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
Fluid overload medications - CORRECT ANSWER- Furosemide
Mannitol
S/S of dehydration - CORRECT ANSWER- •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 - CORRECT ANSWER- •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 - CORRECT ANSWER- •Serum electrolytes (hypernatremia)
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+||BRAND
NEW VERSION!!
Assessment for fluid overload - CORRECT ANSWER- •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 - CORRECT ANSWER- •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 - CORRECT ANSWER- •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 - CORRECT ANSWER- •Isotonic overhydration
•HF and pulmonary edema
•Seizure
•Coma
Causes of fluid overload - CORRECT ANSWER- •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 - CORRECT ANSWER- •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
Fluid overload medications - CORRECT ANSWER- Furosemide
Mannitol
S/S of dehydration - CORRECT ANSWER- •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 - CORRECT ANSWER- •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 - CORRECT ANSWER- •Serum electrolytes (hypernatremia)
