NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
*This is a supplemental tool to help with your studies*
Name: Jessica Cox D#: 41103415
1. Describe what causes fluid volume deficit, and list the clinical manifestations,
nursing management, treatment, and education.
HYPOVOLEMIA - Shift of fluids from plasma into interstitial fluid.
Fluid Volume deficit is HYPOvolemia.
Causes? Fever, heatstroke, Diabetes insipidus, GI losses, hemorrhage, dehydration,
polyuria, burns.
Clinical Manifestations: Poor skin turgor, lethargy, thirst, dry mucous membranes,
decreased urine output/concentration, increased RR, orthostatic hypotension, decrease
cap refill.
Nursing management/assessment: VS changes = decreased BP, Increased HR, increased
RR, flattened neck veins, thready pulse. Check skin turgor, skin for breakdown, daily
weights, I/O’s, LOC, oxygen administration, safe administration of blood.
Treatment: Increase fluids, Blood transfusion
Education: Educate patient of S/S of fluid volume deficit.
NANDA: Fluid imbalance, impaired cardiac output, acute confusion, potential
complication: hypovolemic shock
Client education- Good skin care, if orthostatic hypotension is present, teach to change
positions slowly, remind patient to drink
2. Describe what causes fluid volume excess, and list the clinical manifestations,
nursing management, treatment, and education.
Excess intake of fluids, abnormal retention of fluids, heart failure or renal failure, or a
shift of fluid from interstitial fluid into plasma fluid. Weight gain is the #1 manifestation.
Fluid Volume excess is HYPERvolemia.
Causes? Excessive fluid intake, abnormal retention of fluids (CHF or renal failure),
SIADH, Cushing’s’.
Clinical Manifestations: Increased BP, bounding pulse, edema, HA, crackles/dyspnea,
weight increase, JVD, S3 heart sounds, seizures, coma.
Nursing management/assessments: 24-hour I/O’s, assess cardio changes, respiratory
changes, LOC, PEERLA, daily weights, and skin turgor.
Treatment: Diet, fluid/sodium restriction, fluids, diuretics
Types of diuretics>>
1. Loop diuretics – Furosemide (Lasix)
2. Thiazides – Hydrochlorothiazide
3. Potassium sparing – Spiro lactone
4. Quinazoline - metolazone
Educations: Loop diuretics can cause the kidneys to increase flow of urine; this helps
reduce the amount of water in your body and lower your BP. Take medication in AM.
Thiazides reduce the amount of sodium and water in the body; they are the only type that
dilates the blood vessels, which also helps to lower BP. Potassium-sparing is used to
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
reduce the amount of water in the body; unlike the others, these do not cause your body
to lose K+. Do NOT in increase K+ intake in diet.
3. Describe the laboratory normal values, clinical manifestations, assessment priorities
(i.e. neuro, cardiac, cardiovascular, etc.) & nursing collaborative management of the
below electrolyte imbalances.
Clinical Clinical Assessment Nursing Nursing
Lab Values Manifestations priorities Management Education and
(Include diet) considerations
Hyponatremia Perform a Hypo- - Monitor daily
Hypo-
< 135 mEq/L neurological Replacing fluid weight, I&O and VS
N/V, abdominal
assessment. using isotonic
cramping, weight
gain, cold/clammy Severe sodium- Monitor sodium
skin, fatigue, hyponatremia containing levels
dyspnea, shortness of causes seizures, solutions. -
breath, crackles, confusion and Encouraging oral Hyper-increase
preorbital edema, (+) coma (pg 278) intake. - Withhold fluids
JVD, restlessness,
all diuretics. -
muscle weakness,
Acute or more Hypo- fluid
low urine SG, HCT is
Perform serious, small restrictions
high, seizures/coma.
Hypernatremia neurological amounts of IV
>145 mEq/L assessment for hypertonic saline
hypernatremia. solution (3%
*Think Hypernatremia sodium chloride)
Hyper-
Confusion* causes can restore the
Dry mucous
dehydration serum sodium
membrane, neck vein
which alters the level.
July 2021
, NR 324 ADULT HEALTH EXAM 1 STUDY GUIDE
mental status and
is flat, dry skin,
also causes Hyper - Treat
intense thirst,
drowsiness, underlying cause
oliguria, dark urine,
orthostatic restlessness, -Primary water
hypotension, confusion, and deficit- replace
tachycardia w/ lethargy to fluid orally or IV
thready pulse, seizures and with isotonic
tachypnea, hypoxia, coma. (pg 276)
weight loss.
Hypokalemia -Monitor acid -No potassium- Safety Alert -
Hypo-
>5.0 mEq/L base balance b/c rich foods, No Always dilute IV
Fatigue, Muscle
too much K+ can use of salt KCl and do not give
weakness, leg
cause blood to supplements. in concentrated
cramps, Soft, flabby
become acidic, amounts.
muscles,
Monitor EKG
Paresthesia,
with VS. - Never give KCl via
decreased reflexes,
Hyperkalemia - Monitor blood -Increase IV push or as a
Constipation,
<3.5 mEq/L levels hourly. potassium-rich bolus. - Invert IV
nausea, paralytic
(Can cause foods, administer bags containing KCl
ileus, Shallow
*Think heart* alkalosis) potassium several times to
respirations, Weak,
12 lead EKG for supplements, ensure even
irregular pulse,
Dx monitor EKG and distribution in the
Hyperglycemia
VS. bag. - Do not add
Hyper- KCl to a hanging IV
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