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MOD 5 fluid & electr

Module 5 nur151

QuestionAnswer
bacterial pneumonia causes alveoli to fill with exudate that impairs gas exchange, causing the patient to retain carbon dioxide, which leads to increased PaCO2 and respiratory acidosis.
Burns place patients at high risk for ECV deficit from numerous mechanisms, including plasma-to-interstitial fluid shift and increased evaporative and exudate output
Hemorrhage from any type of trauma causes ECV deficit from blood loss
crush injuries cause hyperkalemia
Head injury typically alters ADH secretion.
Patients who have chronic heart failure have diminished cardiac output, which reduces kidney perfusion and activates the RAAS.
Oliguria occurs when the kidneys have a reduced capacity to make urine.
Blood pressure: Hypotension or orthostatic hypotension is a Extracellular fluid volume deficit.
Light-headedness on sitting upright or standing causes ECV deficit
Rapid, thready indicates ECV deficit
Bounding indicates answer: ECV excess
Neck veins Flat or collapsing with inhalation when supine answer: ECV deficit
neck veins Full or distended when upright or semi-upright answer: ECV excess
Capillary refill: Sluggish answer: ECV deficit
Lung auscultation, dependent portions: Crackles or rhonchi with progressive dyspnea indicate answer: ECV excess
Urine output: Small volume of dark yellow urine, indicate answer: ECV deficit
Presence of edema: Present in dependent areas (ankles or sacrum) and possibly fingers or around eyes, indicate answer: ECV excess
Mucous membranes: Dry between cheek and gum, decreased or absent tearing indicates answer: ECV deficit
Skin turgor: Pinched skin fails to return to normal position within 3 seconds indicates answer: ECV deficit
Presence of thirst: Thirst present indicates answer: Hypernatremia, severe ECV deficit
Restlessness and mild confusion indicate answer: Severe ECV deficit
Decreased level of consciousness (lethargy, confusion, coma) indicates several imbalances such as answer: Hyponatremia, hypernatremia, hypercalcemia, acid-base imbalances
Pulse rhythm and ECG: Irregular pulse and ECG changes indicate answer: K, Ca, Mg, and/or acid-base imbalances
respirations Increased rate and depth indicate answer: Metabolic acidosis (as a compensatory mechanism); respiratory alkalosis (as the cause)
respirations Decreased rate and depth indicate answer: Metabolic alkalosis (as a compensatory mechanism); respiratory acidosis (as a cause)
Muscle weakness indicates answer: Hypokalemia, hyperkalemia
assessing Muscle Reflexes and sensations for Decreased deep tendon reflexes indicates answer: Hypercalcemia, hypermagnesemia
assessing Hyperactive reflexes, muscle twitching and cramps, tetany indicate answer: Hypocalcemia, hypomagnesemia
Numbness, tingling in fingertips, around mouth indicates Hypocalcemia, hypomagnesemia, respiratory alkalosis.
Muscle cramps, tetany indicates answer: Hypocalcemia, hypomagnesemia, respiratory alkalosis
Tremors indicates answer: hypomagnesemia
Inspection and auscultation of GI for Abdominal distention indicates answer: Hypokalemia, third-spacing of fluid
Inspection and auscultation of GI for Decreased bowel sounds indicates answer: Hypokalemia
Inspection and auscultation of GI for Motility: Constipation indicates answer: Hypokalemia, hypercalcemia
0.225% sodium chloride (quarter normal saline; 1/4 NS; 0.225% NaCl) is Hypotonic that answer Expands ECV (vascular and interstitial) and rehydrates cells
0.45% sodium chloride (half normal saline; 1/2 NS; 0.45% NaCl) is answer: Hypotonic that Expands ECV (vascular and interstitial) and rehydrates cells
0.9% sodium chloride (normal saline; NS; 0.9% NaCl) is answer: Isotonic that Expands ECV (vascular and interstitial); but does not enter cells
3% or 5% sodium chloride (hypertonic saline; 3% or 5% NaCl) is answer: Hypertonic that Draws water from cells into ECF by osmosis
Phlebitis and infiltration are the most frequent complications of peripheral IV therapy. To prevent these and other complications such as catheter dislodgement, nurses traditionally stabilized the catheter by taping the hub to the skin
How do diuretics effect fluid balance & electrolytes? can cause metabolic alkalosis, hyper & hypo kalemia
How do steroids cause a fluid or electrolyte imbalance? can cause metabolic alkalosis
How does K supplements cause fluid and electrolyte imbalance? they GI distrbance, intestinal & gastric ulcer 7 diarrhea.
How does respiratory depressants (opioid analgesics) cause fluid and electro imbalances? decrease rate & depth of RR causing respiratory acidosis.
How can antibiotics cause fluid and electro imbalance? Nephrotoxicity from meds like ( vancomycin, methicillin, aminoglycosides) or Hyper K or Na from meds like( azlocillin, carbenicillin, piperacillin, ticarcillin, unasyn)
how does calcium carbonate (tums) cause fluid and electro imbalances? mild metabolic alkalosis with nausea and vomiting
Created by: larue10510