NURSING EXAM 2 GALEN
COLLEGE OF NURSING
QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALES
GRADED A+ LATEST
Causes of fluid overload - 🧠 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 - 🧠 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
Assessment for fluid overload - 🧠 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 - 🧠 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
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