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Nursing 2300 (VIcky Hansen) > Unit 3 - Class Activities > Flashcards

Unit 3 - Class Activities Flashcards

1
Q

The most sensitive assessment parameter(s) for the early detection of fluid volume deficit:

a. orthostatic hypotension and tachycardia
b. blood pressure of 100/70 in the supine position
c. prolonged filling time in the hand veins

A

a. orthostatic hypotension and tachycardia

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2
Q

Describe the osmolality of D5W

A
  • isotonic in the bag

- hypotonic after body metabolizes dextrose

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3
Q

T/F: where sodium goes, water follows

A

T

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4
Q

Describe arteriole and veinous side with Hydrostatic (Filtration) pressure

A

arteriole side is higher than veinous side

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5
Q

I have cirrhosis of the liver and I have gained wt. quickly in the past month. My pants will no longer button in the front. Why?

A

Decreased Oncotic Pressure

- plasma proteins went out of the artery and got pulled into the cells

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6
Q

I’m allergic to shell fish and I had crab last night hidden in a salad…now my face is all puffed up like a balloon. Why?

A

Allergic reactions:

plasma proteins went out of the artery and got pulled into the cells

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7
Q

They say I have thrombophlebitis developed after a long air flight, but how does that explain this leg that is twice the size of the other?

A 
Veinous obstruction:
Hydrostatic Pressure (a hose and kink it)
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8
Q

With this CHF, I can hardly breathe. All this fluid in my lungs “is killing me.” How did it get there? (so much effort that can’t say a full sentence without labored breathing)

A

Hydrostatic pressure & increased sodium

  • heart isn’t pumping enough blood = it thinks they don’t have enough volume = a problem
  • hold onto sodium, hold onto blood = make heart pump harder
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9
Q

The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue?

A. 35 mL per hour
B. 80 mL per hour
C. 50 mL per hour
D. 30 mL per hour

A

D. 30 mL per hour

  • 0.5mL/kg/hr
  • The client weighs 70 kg, so adequate urine output would be 35 mL/hr. The only option lower than 35 mL/hr is 30 mL/hr.
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10
Q

Which factors affect the amount and distribution of body fluids? ( Select all that apply)
Multiple answers:
You can select more than one option

A. Race
B. Age
C. Gender
D. Height
E. Body Fat
A

B. Age
C. Gender
E. Body Fat

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11
Q

Describe Hypervolemia

A

too much volume in the vessels (tied to sodium electrolyte)

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12
Q

What does cirrhosis have to do with

A

perfusion to the kidneys

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13
Q

Which findings indicate that a Patient may have Hypervolemia ( select all that apply)

A. increased, bounding pulse
B. JVD
C. Diminished peripheral pulses
D. Presence of crackles
E. Excessive thirst
F. Elevated blood pressure
G. Orthostatic Hypotension
H. Skin pale and cool to touch
A

A. increased, bounding pulse
B. JVD
D. Presence of crackles
F. Elevated blood pressure

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14
Q

The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client?

A. Heart Failure related to edema, as evidenced by confusion
B. Fluid Volume Deficit related to loss of fluids as evidenced by edema
C. Excess Fluid Volume related to retention of fluids as evidenced by edema and orthopnea
D. Excess Fluid Volume related to congestive heart failure as evidenced by edema and confusion

A

C. Excess Fluid Volume related to retention of fluids as evidenced by edema and orthopnea

*never use a medical diagnosis (CHF) in a nursing diagnosis

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15
Q

The nurse is caring for an elderly client who has been receiving intravenous fluids at 175 mL/hr. The nurse assesses that the client has crackles, shortness of breath, and distended neck veins. The nurse would recognize these findings as indicating which complication of IV fluid therapy?

A. An allergic reaction to the antibiotics in the fluid
B. Fluid volume excess
C. Pulmonary embolism
D. Speed shock

A

B. Fluid volume excess

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16
Q

An older adult patient at risk for fluid and electrolyte problems is vigilantly monitored by the nurse for the first indication of a fluid balance problem.
What is this indication?

A. Fever
B. Mental Status changes
C. Poor Skin turgor
D. Dry Mucous membranes

A

B. Mental Status changes

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17
Q

What is the difference between hypervolemia and overhydration.

A

Hypervolemia: water and salt
Overhydration: just water

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18
Q

What is dehydration

A

fluid volume deficit

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19
Q

Patients with which conditions are at greater risk for deficient fluid volume ( select all that apply)

A. Fever of 103
B. Extensive burns
C. Thyroid crisis
D. Water intoxication
E. Continuous fistula drainage
F. Diabetes insipidus
A

A. Fever of 103
B. Extensive burns (open inflammation, a lot of drainage)
C. Thyroid crisis (breathing faster)
E. Continuous fistula drainage (wound type drainage)
F. Diabetes insipidus (rare condition)

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20
Q

FYI: Good Quizlet to Study:

https://quizlet.com/249289893/iggy-ch-11-assessment-and-care-of-patients-with-fluid-and-electrolyte-imbalances-flash-cards/

A

https://quizlet.com/249289893/iggy-ch-11-assessment-and-care-of-patients-with-fluid-and-electrolyte-imbalances-flash-cards/

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21
Q

The nurse caring for a patient with hypovolemia secondary to severe diarrhea and vomiting. In evaluating the respiratory system for this patient, what does the nurse expect to assess?

A. No changes, because the respiratory system is not involved
B. Hypoventilation, because the respiratory system is trying to compensate for low Ph
C. Increased respiratory rate, because the body perceives hypovolemia as hypoxia
D. Normal, respiratory rate, but a decreased oxygen saturation

A

C. Increased respiratory rate, because the body perceives hypovolemia as hypoxia

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22
Q

The client is receiving fluid replacement. The nurse’s health teaching with this client includes which suggestions? ( select all that apply)

A. measure weight daily
B. Know that thirst means a mild fluid deficit
C. Monitor fluid intake
D. Avoid the use of calcium supplements

A

A. measure weight daily
B. Know that thirst means a mild fluid deficit
C. Monitor fluid intake

23
Q

The mother of a 1-month-old infant calls the nurse who works in the health clinic. The mother is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infant’s mother?

A. Bring the infant to the clinic for evaluation.
B. Give the infant at least 2 ounces of juice every 2 hours.
C. Measure the infant’s urine output for 24 hours.
D. Provide the infant with 50 mL of glucose water.

A

A. Bring the infant to the clinic for evaluation.

24
Q

The Nurse caring for a child at risk for dehydration secondary to diarrhea, vomiting and fever. The child is alert, quiet and clinging to the parent. What is the best nursing intervention to rehydrate this patient?

A. Give an oral rehydration solution such as oralyte or Gatorade
B. Have the parent give small sips of preferred dilute fluids every 5 to 10 minutes
C. Obtain an order for IV access and an isotonic solution such as normal saline
D. Encourage the child to take as much water as possible and offer popsicles

A

B. Have the parent give small sips of preferred dilute fluids every 5 to 10 minutes

25
Q

The client has been placed on a 1,200 mL oral fluid restriction. How should the nurse plan for this restriction?

A. Allow 600 mL from 7–3, 400 mL from 3–11, and 200 mL from 11–7.
B. Instruct the client that the 1,200 mL of fluid placed in the bedside pitcher must last until tomorrow.
C. Offer the client softer, cold foods such as sherbet and custard.
D. Remove fluids from diet trays and offer them only between meals.

A

A. Allow 600 mL from 7–3, 400 mL from 3–11, and 200 mL from 11–7

26
Q

Factors that may cause the risk of hyperkalemia to become chronic include:

A. Blood transfusion
B. Declining renal function in CKD
C. An Injury
D. Excessive Exercise

A

B. Declining renal function in CKD

27
Q

Normal labs for pH

A

7.35-7.45

28
Q

Normal labs for paCo2

A

35-45

29
Q

Normal labs for HCO3

A

21-28

30
Q

Normal labs for PaO2

A

75/80-100

31
Q

Normal labs for K+

A

3.5-5.3 mEq/L

32
Q

Normal labs for Na+

A

135-145

33
Q

Normal labs for Cl-

A

95-105 mEq/L

34
Q

most common furosemide

A

lasix

35
Q

most common furosemide

A

lasix

36
Q

What impacts does sodium have on the body function? (Select all that apply)

a. maintains electroneutrality
b. maintains electrical membrane excitability
c. aids in carbohydrate and lipid metabolism
d. regulates water balance
e. regulates plasma osmolality

A

a. maintains electroneutrality
d. regulates water balance
e. regulates plasma osmolality

37
Q

Describe potassium with hypokalemia

A

Potassium deficit

38
Q

Describe potassium with hyperkalemia

A

Potassium excess

39
Q 
In which compartment is the largest portion of body fluid found?
A. extracellular
B. intracellular
C. intravascular
D. interstitial
A

B. intracellular

40
Q

The most sensitive assessment parameter[s] for the early detection of fluid volume deficit :

A. orthostatic hypotension and tachycardia
B. blood pressure of 100/70 in the supine position
C. lassitude, weakness, and fatigue
D. prolonged filling time in the hand veins
E. decreased serum sodium concentration

A

A. orthostatic hypotension and tachycardia

41
Q

You are caring for Mr. Brown, a 75-year-old patient with congestive heart failure who is receiving IV fluid. You notice that he is becoming increasingly restless and short of breath. His blood pressure and respiratory rate are increasing and he has a moist cough. You also note that he has neck vein distention up to the jaw angle in the sitting position. You hear medium crackles throughout both posterior lung fields.Mr. Brown’s symptoms are most likely caused by:
A. decreased venous return to the right ventricle
B. circulatory overload and pulmonary edema
C. increased tissue hydrostatic pressure in the alveoli
D. decreased tissue hydrostatic pressure in the pulmonary capillaries

A

B. circulatory overload and pulmonary edema

42
Q

The nurse is providing discharge instructions to a client who has been started on furosemide (Lasix) once daily. What information is essential to include in this information?

A.Take the medication at bedtime.
B.Avoid high-potassium foods.
C.Stand up slowly from a sitting position.
D.Do not take this medication on the days you take digitalis (Lanoxin).

A

C.Stand up slowly from a sitting position.

*Clients who are taking diuretics must make position changes slowly in order to minimize dizziness from orthostatic hypotension.The medication should be taken in the morning to prevent awakening at night to void. The client should be encouraged to eat potassium-rich foods and will probably be prescribed a potassium supplement.While clients who take digitalis (Lanoxin) and furosemide (Lasix) are at higher risk for the development of digitalis toxicity, the medications are often taken concurrently. The client and health care provider must monitor these clients closely for the development of digitalis toxicity.

43
Q 
The client who has been taking a diuretic has a serum potassium of 3.4. Which food would the nurse encourage this client to choose from the dinner menu?
A.Baked chicken
B.Green beans
C.Cantaloupe
D.Iced tea
A

C.Cantaloupe

44
Q

The prevalence of hyperkalemia in the hospital setting is:

A. improperly documented
B. 1%-10%
C. 10% – 20%
D. None of the above

A

B. 1%-10%

45
Q

Which Disorder is NOT associated with hyperkalemia?

  • A. Addison’s disease
  • B. Asthma
  • C. Chronic Kidney disease
  • D. Systemic lupus erythematosus
A

•B. Asthma

*All other disorders reduce potassium excretion by the kidneys

46
Q

Which parenteral potassium order is safe for the nurse to implement?

A.Add 20 mEq of KCL to 1,000 mL of IV fluid
B.10 mEq KCL IV over 1–2 minutes
C.Dilute 20 mEq KCL in 3 mL of NS and give IV push
D.10 mEq KCL SQ

A

A.Add 20 mEq of KCL to 1,000 mL of IV fluid

*Parenteral potassium should be well diluted and given IV.It is not given SQ, by IV push, or in limited dilution (such as 20 mEq in 25 mL of fluid).If given in concentrated form, parenteral potassium is lethal to the client

47
Q

The client has been vomiting and has weak flabby muscles that are cramping. The client’s pulse is irregular. The nurse would correctly suspect what type of imbalance?

A.Hypokalemia
B.Hyperkalemia
C.Hypocalcemia
D.Hypercalcemia

A

A.Hypokalemia

*Patients are often asymptomatic, particularly those with mild hypokalemia. Symptoms that are present are often from the underlying cause of the hypokalemia rather than the hypokalemia itself. The symptoms of hypokalemia are nonspecific and predominantly are related to muscular or cardiac function. Signs and Symptoms may include::•Weakness and fatigue (most common)•Muscle cramps and pain (severe cases)•Worsening diabetes control or polyuria•Palpitations•Possibly even: Psychological symptoms (eg, psychosis, delirium, hallucinations, depression)

48
Q

Potassium from dietary intake is primarily distributed to:

A. Bones
B.Red Blood Cells
C.Liver
D.Skeletal muscles

A

D.Skeletal muscles

*About 70% of the total intracellular content is distributed primarily in the skeletal muscles

49
Q

The nurse is caring for a client who is 3-days postoperative. Which intervention should the nurse implement to decrease the client’s possibility of developing hypercalcemia?

A.Measure vital signs every 4 hours.
B.Assist the client to turn, cough, and deep breathe every 2 hours.
C.Assist the client to ambulate around the room at least three times daily.
D.Irrigate the client’s nasogastric tube every 2 hours.

A

C.Assist the client to ambulate around the room at least three times daily.

50
Q

Pick 4 functions of Calcium in the body:

A.Maintain normal cell permeability 
B.Formation of bones/ teeth
C.Maintain gastric Ph 
D.Assist with Insulin production
E.Normal clotting mechanism
F.Normal muscle and nerve activity
A

A.Maintain normal cell permeability
B.Formation of bones/ teeth
E.Normal clotting mechanism
F.Normal muscle and nerve activity

51
Q

Which patients are at risk for developing hyponatremia? Select all that apply

A.Postoperative patient who has been NPO for 24 hours with no IV fluid infusing
B.Patient with slight decreased fluid intake for several days
C.Patient with excessive intake of 5% dextrose solution
D.Diabetic patient with blood glucose of 250 mg/dl
E.Patient with overactive adrenal glands
F.Tennis player in 100 F weather who has been drinking water

A

A.Postoperative patient who has been NPO for 24 hours with no IV fluid infusing
C.Patient with excessive intake of 5% dextrose solution
D.Diabetic patient with blood glucose of 250 mg/dl
F.Tennis player in 100 F weather who has been drinking water

52
Q 
One of the main functions of sodium is to influence the distribution of \_\_\_\_\_\_\_\_\_\_ in the body
A.Water
B.Glucose
C.CO2
D.Bicarbonate
A

A.Water

53
Q

Which of the following situations can cause an increased serum sodium and chloride level:
A. Excessive use of table salt
B.Continuous use of canned vegetables and soups
C.Increased water intake
D.Use of Intravenous 3% saline solutions
E.Use of diuretics

A

A. Excessive use of table salt
B.Continuous use of canned vegetables and soups
D.Use of Intravenous 3% saline solutions

54
Q

Magnesium is responsible for which functions:Select all that apply:
A.Formation of hydrochloric acid
B.Stabilization of excitable membranes
C.Contraction of cardiac muscle
D.Regulation of intracellular osmolality
E.Formation of adenosine triphosphate (ATP)

A

B.Stabilization of excitable membranes
C.Contraction of cardiac muscle
E.Formation of adenosine triphosphate (ATP)

Nursing 2300 (VIcky Hansen) (64 decks)

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