Nursing 105 Final Exam Study Guide with Complete Solutions 2024 Clinical Manifestations for Dehydration - Correct Answer *Increased thirst *Dry mouth and swollen tongue *Weakness *Dizziness *Palpitations (feeling that the heart is jumping or pounding *Confusion *Sluggishness fainting *Decreased urine output *Changes in mental status *Kidney *Endocrine (poor regulation of sodium and potassium *Nausea *Vomiting Assesssment findings for Dehydration - Correct Answer *Pulmonary edema *Poor skin turgor (check for skin turgor on the chest and the forehead) *Weight loss *Reduced urine output *Cardiovascular changes (heart rate increases) *Respiratory changes (increased rate) *Peripheral pulses weak *Hypotension while standing *Kidney changes *Neurologic changes (confusion) *Neck Vein Distention Risk factors for dehydration - Correct Answer *Older adults are unable to obtain fluids without help *Older patients have less total body water than younger adults *Decreased thirst sensation 1 / 3
*Diuretics *Antihypertensives *Laxatives Nursing Interventions for Dehydration - Correct Answer Patient Safety Fluid Replacement Drug Therapy (Oral or IV fluid replacement) Best Indicator for fluid volume loss - Correct Answer Daily Weight (same time every day) Patient Teaching for Dehydration - Correct Answer Drink more fluids, mainly water, matching fluid intake with fluid output Clinical Manifestations of Hypokalemia - Correct Answer Diuretics Digitalis Corticosteroids Diarrhea Vomiting Prolonged nasogastric suction NPO Assessment Findings for Hypokalemia - Correct Answer Respiratory Musculoskeletal Cardiovascular Neurologic Intestinal *All of these conditions are weakened
Interventions for Hypokalemia - Correct Answer Drug Therapy:
*Potassium via IV is given for more severe *Oral potassium is given as a liquid or solid 2 / 3
*Drugs given are Aldactone, Novospiroton, Dyrenium,Midamor
Nutrition Therapy:
*Teach patient how to increase potassium intake *Eat foods that are naturally rich in potassium to prevent further loss
Safety Measures:
*Fall precautions
Respiratory Monitoring:
Pulse oximetry (O2 Sat) Hypocalcemia - Correct Answer Low calcium levels (below 9.0 mg/dl) Clinical Manifestations of Hypocalcemia - Correct Answer Inadequate oral intake of calcium Lactose intolerance Inadequate intake of Vitamin D End Stage Kidney Disease Diarrhea Wound Drainage Assesssment Findings of Hypocalcemia - Correct Answer *Neuromuscular changes - Paresthesias occur with sensations of tingling and numbness *Cardivascular changes - Heart rate increase or decrease with weak threading pulse *Intestinal changes - Abdominal cramping or diarrhea *Skeletal changes - Osteoporosis Nursing Priority for Hypocalcemia - Correct Answer *Drug Therapy: Calcium replacement oral and IV
*Nutrition Therapy: High Calcium Diet
*Reducing environmental stimuli *Preventing Injury
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