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EXAM 2: NUR242/ NUR 242 MEDICAL -SURGICAL
NURSING EXAM REVIEW| QUESTIONS AND
VERIFIED ANSWERS| 100% CORRECT- GALEN
QUESTION: What are the causes of fluid overload?
Answer: Causes of fluid overload •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
QUESTION: What are the signs and symptoms of fluid
overload?Answer: s/s fluid overload •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
QUESTION: How should a nurse assess for fluid overload?
Answer: Assessment for fluid overload •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:
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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
QUESTION: What lab values are associated with fluid
overload?
Answer: Lab values fluid overload •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
QUESTION: What are the interventions and goals for fluid
overload?Answer: fluid overload interventions/goal •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
QUESTION: What are complications of fluid overload?
Answer: Fluid overload complications •Isotonic overhydration
•HF and pulmonary edema •Seizure •Coma
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QUESTION: What medications are used for fluid overload?
Answer: Fluid overload medications Furosemide Mannitol
QUESTION: What are the signs and symptoms of dehydration?
Answer: S/S of dehydration •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
QUESTION: How should a nurse assess for dehydration?
Answer: Dehydration assessment •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
QUESTION: What lab values are associated with dehydration?
Answer: Dehydration labs •Serum electrolytes (hypernatremia)
•Increased serum osmolality normal 275- 295 mOsm/kg; elevated > 295 found in dehydration; > 320 is critical finding •CBC elevated H/H •Elevated urine specific gravity > 1.030 •Increased BUN
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QUESTION: What are the interventions and goals for
dehydration?Answer: Dehydration interventions/goal •Goal of interventions: replace fluid and electrolytes to achieve homeostasis •Closely monitor status and rehydration, avoid overcorrection •Monitor I/O and weight •Identify and manage cause- diarrhea, vomiting, blood loss, poor intake •Oral rehydration is priority if tolerating PO fluids
QUESTION: What are priority interventions for dehydration?
Answer: Dehydration priority interventions •IV fluid
resuscitation/replacement, general guidelines •Hypertonic dehydration- hypotonic fluids- D5W once dextrose is metabolized; 0.45% NaCL (1/2 normal saline) •Isotonic
dehydration: isotonic fluids (normal saline, lactated ringers)
•Hypotonic dehydration: hypertonic fluids (3% or 5% saline
solution) •Blood products in increased blood loss/trauma
•Medications to treat cause: antidiarrheal, anti emetic, AB,
antipyretics •Ingestion of food to replace electrolytes
QUESTION: What are complications of dehydration?
Answer: Complications of dehydration •Hypovolemia
•Hypovolemia shock •Seizures/coma •Multiorgan system failure