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Exam 5 NUR 215 Questions with Latest Update
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Exam 5 NUR 215 Questions with Latest Update
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Exam 5 NUR 215 Questions with LatestUpdate
What to look for when assessing fluid balance: - Answer-- check for edema
- stable blood pressure
- moist pink mucous membranes
- lung sounds (fluid loves the lungs...crackles?)
- skin turgor
- daily weights
2 diagnoses for fluid balance/electrolytes: - Answer-- fluid excess
- fluid deficit
implementation stage for nurses during fluid balanace/ electrolyte imbalance - Answer--
raise legs
- decrease sodium intake
- record I/O's
- daily weights
fluid compartments - Answer-Intracellular fluid (ICF): approx. 65% of body's water inside
cells
Extracellular fluid (ECF): approx 35% of body's water outside cells
water flows freely between 2 compartments
hypervolemia - Answer-fluid overload
excess fluid outside cells ( can lead to confusion)
ex: -increased bp
- edema
goal: return to homeostasis by elevating feet and applying ted hose
hypovalemia - Answer-fluid deficit
ex: - dry mucous membranes
- decrease bp, tachycardia
- increase pulse
- hypotension
- decrease urine
- increase BUN
- increase creatinine
sources of Potassium (k) - Answer-diet: spinach, bananas, potato, orange juice
, IV, oral med
*if they have too high Vit K increase BM to rid the Vit K*
Range 3.5-5.0
Sodium (Na) - Answer-brain swelling is possible
- activates nerves and muscle cells
Range 135-145
Oxygen home safety - Answer-no smoking w/in 10ft of oxygen in use
- place a "no smoking" or "oxygen in use" sign on the front door
- know where the fire extinguisher is located
- do not wear synthetics or wool
- ensure all electrical devices are working well
- make sure electric machinery is grounded
- do not use flammable materials ( alcohol, acetone) near oxygen
seizure precautions - Answer-- have rescue equipment at bedside (oxygen, suction
equipment, oral airway, padding for side rails)
- saline lock in place for IV
- inspect environment for environmental hazards that could cause injury during a
seizure
- assist with ambulation and transferring
- advice caregivers and family members not to out anything in clients mouth during a
seizure except for an airway
- advise others not to restrain client during seizure but to lower to the ground, remove
nearby harmful equipment, protect head, provide privacy, put on their side and flex head
slightly, loosen clothing
Pt. is at high risk for seizures which is priority equipment needed?
a. padded side rails
b. oxygen
c. saline lock in place
d. all of the above - Answer-c. saline lock in place
rationale: to be able to push seizure medications and have route (I THINK)
while having seizure order for family: - Answer-- nothing in mouth
- no restraints
- protect head
- remove nearby furniture
- place pt. on side
- loosen clothing
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