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Terms in this set (55)Fluid Volume Excess: Hypervolemia Define: too much fluid in the vascular space FVE Causes: Heart Failure: heart is weak = decreased CO, kidney perfusion, UOP = volume stays in vascular space Renal Failure: kidneys are not working = decreased UOP = retention = volume stays in vascular space Things with a lot of Sodium Hormonal Regulation of Fluid Volume Aldosterone: Location: adrenal glands Anti-diuretic Hormone: Location: pituitary gland
SIADH: Define: too much ADH * too many letters too much water * DI: Define: too little ADH *DI = DIuresis * FVE S/S: distended neck veins FVE Treatment: low sodium diet Fluid Volume Deficit: THINK SHOCK FVD Causes: Loss of fluid from anywhere FVD S/S: weight
loss FVD Treatment: prevent further loss Isotonic IVF: Action: goes into vascular space and stays there Alert: do not use isotonic IVF in clients with HTN, cardiac or kidney disease Hypotonic IVF: Action: goes into vascular space and then shifts out into the cells to replace fluid Alert: watch for cellular edema = FVD = decreased BP Hypertonic IVF: Action: volume expanders that will draw fluid into the vascular space from the cell Alert: watch for FVE, must be placed in the ICU for close monitoring IVF Quick Tip: Isotonic Solutions = "Stay where I put it" Hypotonic Solutions = "Go Out of the vessel" Hypertonic Solutions = "Enter the vessel" Hypermagnesemia: Mg: 1.3 to 2.1 Symptoms: Treatment: Hypercalcemia: Calcium: 9.0 to 10.5 Symptoms: Treatment: Hypomagnesesmia: Causes: diarrhea and alcohol Symptoms: Treatment: Hypocalcemia: Causes: hypoparathyroidism, radical neck, thyroidectomy Symptoms: Treatment: Hypernatremia = Dehydration: Sodium: 135 to 145 Symptoms: Treatment:
Hyponatremia = Dilution: Causes: drinking H2O, psychogenic polydipsia, D5W, SIADH Symptoms: headache, seizure, coma Treatment: Hyperkalemia: Potassium: 3.5 to 5.0 Symptoms: * in this order * Treatment: * any time you are giving insulin IV worry about hypokalemia and hypoglycemia * Hypokalemia: Causes: vomiting, NG suction, diuretics, not eating Symptoms: * in this
order * Treatment: Miscellaneous Info about Potassium: major problem with PO potassium - GI upset Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function? A. Assessing dietary intake A. Assessing dietary intake A 12-year-old boy was admitted to the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing interventions should be included in the care plan for the client? A. Room temperature reduction A. Room temperature reduction Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury? A. "I do not have to see my doctor unless I have problems." C. "If I have redness, drainage, or fever, I should call my healthcare provider." Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? Select all that apply. A. Clustering activities to allow uninterrupted periods of rest. B. Maintaining correct body alignment at all times.
A 36-year-old male client is about to be discharged from the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse's instructions about measures to prevent constipation? A. Discouraging the client from eating large amounts of roughage-containing foods in the diet. D. Instructing the client to fill a 2-L bottle with water every night and drink it the next day. Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale? A. Nutritional needs remain unchanged for the well-nourished adult. C. The presence of infection may slow the healing process. A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury? A. Administering anti-inflammatory agents as prescribed. A. Administering anti-inflammatory agents as prescribed.
Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling? A. Inserting an indwelling Foley catheter. B. Having the client perform Kegel exercises. Jeron is admitted to the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client? A. Prevention of fluid volume excess B. Maintenance of adequate oxygenation Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care? A. Stress-reduction techniques B. Home environment evaluation Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client's need to maintain skin integrity? A. Monitoring intake and output accurately. C. Keeping the linens dry and wrinkle-free. Maya, who is admitted to a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first? A. Massage the reddened area for a few minutes. D. Turn the client to the right side for 2 hours. Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do? A. Administering the client's ordered pain medication immediately. D. Attempting to rule out complications before administering pain medication. Nurse Martha is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganisms? A. Maintenance of asepsis with indwelling catheter insertion. C. Correct handwashing technique. A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark's care. Which nursing intervention should be included in the care plan of Mark for his patient? A. Administering I.V. and oral fluids. A. Administering I.V. and oral fluids. Khaleesi is admitted to the hospital due to having a lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase? A. Whole grains and nuts D. Orange juice and bananas Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis? A. Administering sodium chloride I.V. B. Encouraging slow, deep breaths. Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client's intake? Fill in the blank. 2,470 mL 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the shift Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated? A. Positive Trousseau's sign A. Positive Trousseau's sign Lab tests revealed that patient Z's [Na+] is 170 mEq/L. Which clinical manifestation would nurse Natty expect to assess? A. Tented skin turgor and thirst A. Tented skin turgor and thirst Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client's blood gas values through improved ventilation and oxygen therapy, which is the client's primary stimulus for breathing? A. High PCO2 B. Low PO2 A client with a very dry mouth, skin, and mucous membranes is diagnosed with dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit? A. Assessing urinary intake and output. A. Assessing urinary intake and output. Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium? A. A 14-year-old who is taking diuretics. D. An 18-year-old who has renal disease. Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate? A. Instituting seizure precaution to prevent injury. A. Instituting seizure precaution to prevent injury. Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid? A. Potassium D. Sodium Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate? A. Potassium supplements B. Kayexalate Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia? A.
Muscle pain and acute rhabdomyolysis B. Hot flushed skin and diaphoresis Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client? A. Sodium level C. Potassium level Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement? A. Instructing the client to breathe slowly into a paper bag. C. Encouraging the client to cough and deep breathe. A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order? A. Potassium B. Sodium bicarbonate Other sets by this creatorPathology Medical Terms :9 terms jennifershareee Colors Medical Terms :13 terms jennifershareee Endocrine System Medical Terms :11 terms jennifershareee Male Reproductive Medical Terms :11 terms jennifershareee Other Quizlet setsCommunications Test 2147 terms StephanieBedoya A&P ch 10124 terms Ashlynn___Jenkins The Crucible - Act One12 terms SnellL1 Respiratory system37 terms mngebrael Which electrolyte should the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?Sodium, the most prominent electrolyte 'solute' in extracellular fluid, is used to monitor extracellular osmolarity.
When caring for a client who has hypokalemia which electrocardiogram change will the nurse expect to observe?1. A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves.
Which patient is at the highest risk for developing hypokalemia?The following risk factors are known to be associated with an increased risk of hypokalemia:. Female.. Medications like diuretics.. Heart failure.. Hypertension.. Low BMI.. Eating disorder and alcoholism: low intake of potassium.. Diarrhea, cushing syndrome, and any condition that cause increase potassium loss.. Which patient is at most risk for fluid volume deficit quizlet?Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any other age group.
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Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium quizlet?
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