226 Fluid imbalance quiz

HYPERCALCEMIA

Prolonged bedrest, Hyperparathyroidism, Bone Malignancy, Paget disease and osteoporosis are potential causes of what?

FLUID OVERLOAD

Excess of fluid intake, not enough fluid going out, heart failure (ineffectively pumping), Kidney (renal) failure and excess sodium intake can contribute to?

HYPOCALCEMIA NURSING INTERVENTIONS

Monitor HR and Rhythm, Continuous EKG monitoring, Initiate fall and seizure precautions, Administer oral and IV supplements as ordered, Encourage calcium rich foods.

INTERVENTIONS FOR HYPERKALEMIA (6.0 mEq/L)

Dialysis, potassium wasting diuretic, stop potassium supplement, give both insulin and dextrose

HYPERVOLEMIA

Fluid overload

HYPOVOLEMIA

Fluid deficit, can be fluids or blood

INTERVENTIONS FOR HYPERVOLEMIA

Reduce fluid intake, Administer oral diuretics, strict I&O, limit salt, Daily weight, Dialysis and frequent heart, skin, lung and neuro assessments

HYPERKALEMIA CAUSES

Renal impairment, overuse of potassium replacements, excess intake of potassium rich foods, trauma (cell lysis), acidosis, adrenal insufficiency, potassium-sparing diuretic (spironolactone, triamterene, amiloride)

What kinds of foods must be limited for a patient who has a sodium level of 163 mEq/L?

Processed foods: hot dogs, deli meats, cheese, bakery items, most canned items (soups, veggies), chips, crackers, (many others)

What kind of electrolyte problems may occur in a patient who has GI (gastrointestinal)

problems?

Primarily Mg and Ca issues (both absorbed in GI tract). If GI tract not working well, appropriate absorption of these two electrolytes will be impacted (if GI slow, may absorb too much; if GI fast, may not absorb enough 

signs and/or symptoms of fluid volume deficit

confusion, thirst, dry mucous membranes, orthostatic hypotension, tachycardia, weak and thready pulse, decreased skin turgor, prolonged capillary refill, and decreased urinary output flushed dry skin, increased body temperature, irritability, seizures, coma

What assessment findings does the nurse anticipate in a client with a magnesium level less than 1.3 mEq/L?

EKG changes, tachycardia, rapid shallow respirations, irritability, insomnia, hyperactive DTRs, cramping, clonus (hyperflexion), MAYBE positive Chostek/Trousseau's signs, seizures

Name the 3 types of crystalloid IV solutions and give an example of each

Hypotonic: 0.33% NS, 0.45% NS

Isotonic: 0.9% NS, LR(lactated ringer), 5% dextrose and water (D5W)

Hypertonic: D5LR, D5 0.9% NS, D5 0.45% NS, 3%NS

What interventions may be used to treat a potassium level of 3.2 mEq/L? (hypokalemia)

Give potassium supplement (oral or IV-but NO IV push!), give potassium-rich foods, stop K-wasting diuretic, medicate to stop vomiting/diarrhea, stop sweating

Infiltration

Infusion of IV solution and/or nonvesicant medications into surrounding tissues

Occlusion

Partial or complete obstruction of a vascular access device, IV flow is sluggish or stopped.

Catheter-related infection

Local infection that occurs at insertion site. Local symptoms: Pain at site, tenderness, erythema (redness), swelling, increased temperature, purulent drainage

Phlebitis

Inflammation of the vein

Extravasation

Inadvertent infusion of vesicant (causing blisters, ulceration, sloughing) or irritating solution or medication into surrounding tissues.

causes of Respiratory alkalosis

Pain

Hyperventilation

Salicylate overdose

Nicotine overdose

Increased metabolic states

What are 3 major causes of hypernatremia?

Fluid loss (lose more fluid than sodium), sweating (may lose more fluid than sodium), too much processed food, tube feedings without water supplement, renal impairment, hyperaldosteronism (too much aldosterone release), limited water intake

List 3 interventions for hypovolemia. Also include how/why the selected interventions are helpful.

Oral/IV fluid replacement, stop diuretics, medicate to prevent vomiting/diarrhea (if appropriate), medicate to treat fever or other illness (if appropriate)

What assessment findings does the nurse expect in a client with a magnesium level of

3.2 mEq/L (hypermagnesemia)

Low and slow: bradycardia, EKG changes (cardiac arrest is possible), slow shallow respirations, fatigue, drowsy, lethargy, decreased DTRs, decreased muscle strength, generalized weakness

What kind of foods must be limited in a patient who has a potassium level of 5.3 mEq/L?

Organ/preserved meats, dairy, dried fruit, bananas, cantaloupe, avocado, broccoli, potatoes, spinach

What are nursing interventions for metabolic alkalosis?

Assess vital signs

Monitor cardiac rate and rhythm, respiration rate and rhythm

Monitor ABG's and electrolytes

Assess LOC

Administer oxygen as ordered

Initiate seizure precautions

Treat hypokalemia if appropriate

What are 5 causes of dehydration?

Not enough fluid in or too much fluid out.

NPO status, vomiting, diarrhea, sweating, wound drainage, hemorrhage, GI suction, severe burns.

How can dehydration be treated?

oral/IV fluid replacement, stop diuretics, prevent further fluid loss (vomiting, diarrhea, hemorrhage)