Galen NUR 242 Exam 2 (2026 / 2027) | Med-Surg Nursing | (A+ Guarantee) | PDF

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

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

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: 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

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

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

Fluid overload complications

•Isotonic overhydration

•HF and pulmonary edema

•Seizure

•Coma

Fluid overload medications

Furosemide

Mannitol

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

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

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

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

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

Complications of dehydration

•Hypovolemia

•Hypovolemia shock

•Seizures/coma

•Multiorgan system failure

Dehydration medications

Diphenoxylate with atropine

Loperamide

Promethazine HCL

Acetaminophen

Causes of hypercalcemia

•increased intake of calcium, antacids, thiazide, glucocorticoids, kidney disease, immobilization, calcium and vitamin D overdose, acidosis, milk alkali syndrome, bone metastasis, hyperparathyroidism

Causes of hypocalcemia

low calcium intake, lactose intolerance, Malabsorption syndrome (crohn's disease) End stage kidney disease, diarrhea, wound drainage (especially GI)

Calcium

9-10.5

S/S of hypocalcemia

•Vital signs: SB, low hypotension, weak pulses

•Assess for tetany, Chvostek sign, trousseau sign, laryngeal stridor, dysphagia, fatigue, anxiety, depression, hyperreflexia, muscle spasm numbness, tingling of extremities and around mouth

S/S of hypercalcemia

•Vital sign, ST, HTN, bounding pulses

•Assess for lethargy, weakness, confusion, decreased reflexes, N/V, bone pain, fractures, polyuria, kidney stone

Hypercalcemia ECG changes

short ST segment wide T wave

Hypocalcemia ECG changes

prolonged ST segment, prolonged QT segment

Hypercalcemia interventions

•Determine and manage underlying causes

•High calcium level may be associated with renal lithiasis; strain urine and assess for kidney /flank pain

•High Ca+ may exacerbate digoxin toxicity

•Diuretic

•Cardiac monitoring

•Hydrate with isotonic saline /oral hydration or 3000 to 4000 mL/day

•Low calcium diet

•Increase weight bearing exercise

Hypocalcemia interventions

•Treat the underlying causes

•Assess client with neck or thyroid surgery for potential parathyroid damage

•Manage pain and anxiety of clients at risk for hypocalcemia

• Respiratory alkalosis may exacerbate symptoms

•Increase calcium diet and vitamin D

•Administer IV calcium gluconate, monitor ECG and IV site

•Weight bearing exercise

Hypercalcemia complication

coma

Hypocalcemia complications

seizures, laryngospasm, VT

Medications for hyper/hypocalcemia

Furosemide

Calcitonin

Pamidronate

•Nitrogen containing bisphosphonate used to treat osteoporosis

Potassium

3.5-5

Hyperkalemia causes

•Acidosis, cellular lysis(burns, injury, infection), medication maintain K+ in intravascular space, potassium oral, rapid or high dose infusion of IV potassium, renal failure, adrenal insufficiency, overuse of K+ salt substitute, use of K+ sparing diuretic, and hyperuricemia, ACE's

Hypokalemia causes

•rhea, vomiting, inadequate intake of potassium, overuse of laxatives, low magnesium levels, massive diuretic, side effect of insulin treatment with diabetic ketoacidosis, stress, delirium tremens, coronary muscle necrosis, alkalosis, wound drainage (GI), diaphoresis, kidney disease, water intoxication, NG suction

S/S of hyperkalemia

Asked about drug use

potassium supplements, ACEs, K+ sparing,

Palpation, irregularities rhythms, twitching leg weakness, tingling or numbness of hands, feet, or face. ECG changes of tall, peaked T waves

GI: increase motility with diarrhea and hyperactive BS, BM are frequent and watery

S/S of hypokalemia

•Assess vital sign (irregular weak thready pulses, shallow respiration, orthostatic hypotension)

•Observe for muscle weakness, leg weakness, paralytic ileus, hyperglycemia, paralysis, anxiety, confusion, lethargy, paresthesia, depressed deep tendon reflexes

Hyperkalemia ECG changes

peaked T waves, prolonged PR interval, ST depression, loss of p waves, prolonged QRS

Hypokalemia ECG changes

•ST depression, flattened T wave, prolonged QRS, PVCs

Hyperkalemia interventions

•Determine and manage underlying cause

•Decrease oral or IV intake of K+ (restrict diet)

•Potassium binding med

•IV infusion of insulin with glucose to force K+ into the cell and reduce serum K+

•IV infusion of calcium gluconate or sodium bicarbonate to decrease cellular cardiac excitability

•Dialysis

•Provide K+ restrict diet (avoid avocados, broccoli, dairy products, bananas)

hyperkalemia nutrition

•You should avoid organ meat, preserved meat, dairy products, dried fruit, bananas, cantaloupe

•Vegetables: avocados, broccoli, dried bean or peas, potatoes, spinach

Hypokalemia interventions

•Oral and IV supplementations

Ensure adequate gas exchange

Safety for falls prevention

Monitor signs and symptoms

Monitor lab values

Potassium diet

Hyperkalemia complications

•V fib

•Complete respiratory arrest

•Cardiac standstill/arrest

Hypokalemia complications

•Lethal cardiac dysrhythmias

•Coma

•Cardiac arrest

Medications for Hyper/hypo kalemia

•Furosemide

•Potassium chloride

Clinical Hints:

•Both hyper and hypo lead to cardiac irritability and dysrhythmias

•Monitor ECG closely and report to physician

Hypermagnesemia causes

•increase magnesium intake

•Antacid and laxative with magnesium containing

•Decrease kidney excretion of magnesium resulting in kidney disease

S/S of hypermagnesemia

•CV: Bradycardia, hypotension, respiratory depression

•CNS: drowsy, lethargic, coma if prolong

•GI; N/V

•Neuromuscular: absent deep tendon reflexes, voluntary skeletal muscle contractions, respiratory muscle are weak

Hypermagnesemia interventions

•Determine and manage underlying cause

•Focus is on prevention

•Avoid mag containing foods (green vegetables, nuts, bananas, orange, peanut butter, chocolate)

•Emergency treatment: calcium gluconate or calcium chloride

•Promote urinary excretion with IV fluids, oral fluids, and IV furosemide

•Impair renal function use dialysis to draw off mag

Magnesium

1.5-2.5

Hypomagnesemia causes

•Malnutrition

•Starvation

•Diarrhea

•Crohns disease

•Drugs (diuretics, aminoglycoside AB)

•Ethanol ingestion

Hypomagnesemia S/S

•Hypertension, skeletal numbness and tingling, painful muscle contraction

•Chvostek and Trousseau signs

•Decrease motility, anorexia, N, constipation, abdominal distention

Hypomagnesemia interventions

•Determine and manage underlying cause

•Dietary replacement of mag supplements/mag containing foods

•With significant deficits, provide IV mag

•Assess deep tendon reflexes when receiving magnesium IV infusion

Hypermagnesemia complications

•Paralysis

•Respiratory and cardiac arrest

Hypomagnesemia complications

•Seizures

•Dysrhythmias - VT, VF

Magnesium enhances ______________ toxicity

digoxin

Hyper/hypo magnesiemia medications

Furosemide

Monitor IV infusion of mag, to rapid infusion may lead to ___________ or ____________ _____________

cardiac or respiratory arrest

Chvostek and trousseau signs are often the signs of _____________________ or ____________________

hypocalcemia or hypomagnesemia

Sodium

135-145

Hypernatreamia causes

•Causes: Kidney failure, corticosteroids, Cushing's syndrome or disease, excessive oral sodium ingestion, excessive administration of sodium-containing IV fluids, dehydration, watery diarrhea

•Fever, hyperventilation, NPO, infection

Hyponatremia causes

excessive diaphoresis, diuretics, hyperlipidemia, kidney disease, low salt diet, hyperglycemia, heart failure, kidney failure

Hypernatremia assessment

•Assess vital sign for low BP, postural hypotension

•Assess skin for poor turgor and dry/swollen tongue

•Assess LOC for agitation, lethargy , weakness

•Ask about thirst, sodium intake, water intake

•Determine if client is exhibiting hypernatremia with decreased or increased extracellular volume

Hyponatremia assessment

•Assess level of consciousness, (change in neuro function may be first symptom from cerebral edema) for HA, Confusion, and irritability

Hypernatremia interventions

•Monitor electrolytes

•Determine underlying cause

Administer oral or IV hypotonic or isotonic fluids

Limit sodium intake

Diuretic to pull off sodium

Hyponatremia interventions

•Fluid restriction

•Replace hyponatremia r/t fluid loss, with sodium containing fluid

•Administer small volumes of hypertonic solution titrated to serum osmolality and sodium level if seizure develop

•Monitor sodium levels

hyper/hyponatremia complications

•Seizure

•Coma

•Neurological damage/coma

Hyper/hyponatremia medications

Hydrochlorothiazide diuretics (HCTZ)

•Pull off excess fluids and Na+

•Used with diabetes insipidus

metabolic acidosis causes

•diabetic ketoacidosis (DKA), lactic acid accumulation when in shock or after a trauma,•loss of HCO3 from diarrhea, starvation

•renal tubular necrosis, GI fistulas, aspirin overdose

• high fat diets, ineffective metabolism of carbohydrates, and renal disease that impairs ability to reabsorb HCO3

Metabolic acidosis S/S

•Assess s/s of respiratory distress

•vital signs for low BP, tachypnea (hyperventilation), dysrhythmias

•Skin: warm and flushed

•Neuro: drowsiness, confusion, HA

•GI: diarrhea, N/V abdominal pain

•Neuromuscular: Tetany, numbness, twitching,

Metabolic acidosis labs

•pH decreased

•PaCO2 normal (uncompensated)

•PaCO2 decreased (compensated)

•HCO3 decreased

•Monitor potassium level (elevated from compensation)

Metabolic acidosis interventions

•Determine/manage underlying cause

•Establish seizure precautions

•Assess I/O

•Provide NaHC03 via IV

•Treat DKA with insulin and hydration

•Clients with kidney disease are treated with dialysis and a low protein/high calories diet

Metabolic acidosis complications

•Seizures

•Coma

•Polyuria/osmotic diuresis/diarrhea may lead to hypovolemia and shock

Metabolic acidosis education

•Teach DM about sick day care and means to avoid DKA

•Report s/s out of the ordinary to Dr.

Metabolic alkalosis causes

•vomiting, NG suctioning, diuretics, hypokalemia, increased mineral corticoids, eating baking soda,/infusion of excess NA HCO3, hyperaldosteronism, large blood transfusion wherein citrates bind with HCO3

•May occur with respiratory acidosis (client with COPD on thiazide diuretic)

•Ma occur with respiratory alkalosis ( hypo-ventilating and losing gastric acids via NG drainage)

Metabolic alkalosis S/S

•Vital signs: ST, Bradypnea

• increased work of breathing or respiratory distress (hypoventilation)

•Neuro: dizziness, confusion, restlessness followed by lethargy

•GI: N/V, diarrhea, anorexia

•neuromuscular: tetany, muscle cramps, tremors, tingling of fingers and toes

Metabolic alkalosis labs

•pH increased

•PaC02 normal (uncompensated)

•PaC02 elevated (compensated)

•HC03 increased

•Monitor potassium level (low from compensation)

•Monitor calcium level

pH

7.35-7.45

PaCO2

35-45

HCO3

22-26

Metabolic alkalosis interventions

•Determine/manage underlying causes

•Implement seizure precaution

•Replace K+

•Medications to increase excretion of bicarbonate

•Read and interpret ABGs findings, watch for trend/changes

•Maintain safety precaution with change sensorium

•Assess clients with profuse vomiting/Gastric suctioning for changes in LOC

•Instruct the importance of hydration

•s/s that need reported to Dr.

Metabolic alkalosis complication

seizures

respiratory acidosis causes

•COPD

•barbiturate/CNS depressants/opioid overdose,

• pneumonia, asthma, atelectasis, low respiratory rate on ventilator, hypoventilation, respiratory muscle weakness (Guillain Barre, Myasthenia gravis), high oxygen provision to C02 retainers,

•pulmonary edema, and pulmonary embolism

respiratory acidosis S/S

Vital signs: hypotension, rapid, shallow respiration

• airway for obstructive or respiratory depression

•Neuro: dizziness, drowsiness, confusion, HA

• Skin: Mucosa Pale to Cyanotic

•Neuromuscular: weakness, hyper reflexia, seizures

respiratory acidosis labs

•pH decreased

•PaC02 increased

•HC03 normal (uncompensated)

•HCO3 increased (compensated)

•Monitor K+ elevated

respiratory acidosis interventions

•Determine/manage the underlying causes

•Provide 02

•Position semi fowler

•Encourage to turn, deep breath and cough

•Encourage fluids to liquefy secretions, suctions as needed

•Avoid medications that causes respiratory depression

•Provide respiratory treatments and AB as prescribed

•Monitor for rising C02 and need for intubation and mechanical ventilation

•Implement seizure precautions as indicated

•Monitor clients at risk for and symptoms of increasing respiratory distress

•Read and interpret ABG findings, watching for trends and change

•Respiratory distress is very frightening for clients requiring nurses to provide support and remain calm

respiratory acidosis complications

•Seizures

•Coma

•Ventricular fib

Respiratory acidosis education

•Instruct to assess for deteriorating respiratory condition

•Educate client on means to prevent respiratory infections

•

• Clinical Hint: client who are carbon dioxide retainers respond to the hypoxic drive to breath. If client receive high oxygen levels, this may be extinguished causing apnea

respiratory alkalosis causes

• hyperventilation, hypoxia,

• pulmonary embolism, fear, fever, anxiety,

•overventilation during exercise, brain injury/encephalitis, septicemia,

• salicylate poisoning, and overventilation via mechanical ventilatory

•May occur with metabolic alkalosis (hypoventilation and losing gastric acids via NG drainage.)

Respiratory Alkalosis S/S

vital signs for ST, tachypnea, Deep rapid breathing

•Neuro: confusion, lethargy, light headedness

•Skin: warm, flushed

•GI: N/V,D, abdominal pain

•Neuromuscular: numbness, tingling of extremities, seizures

respiratory akalosis labs

•pH increased

•PaC02 decreased

•HC03 normal (uncompensated)

•HC03 decreased (compensated)

•Monitor potassium elevated

•Monitor calcium

respiratory alkalosis interventions

•Determine/manage underlying cause

•Provide emotional support

•Encourage normal breathing patterns

•Teach client means to retain C02

•Holding breath

•Use a rebreathing mask

•Breathing into a paper bag

•Alleviate hypoxemia to lower respiratory rate, ensure adjustment of ventilator settings

•Implement seizure precautions, as indicated

respiratory alkalosis complications

seizure

respiratory alkalosis medications

•Calcium carbonate, calcium gluconate

•Treats respiratory alkalosis,

• hyperphosphatemia, and hypocalcemia

•Monitor for tetany