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NUR 390 Exam 1 Questions

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  • Course
  • NR NUR390 (NUR390)
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  • Chamberlain College Of Nursing

Minimum urine output? - 0.5ml/kg/hr How to calculate MAP? - Double diastolic + systolic / 3 Below 65 (or 70 in a healthy person) means the organs are not being properly perfused. This is a critical situation. Used to identify hypotension Nursing intervention for monitoring fluid volume - MAP ...

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  • December 24, 2023
  • 21
  • 2023/2024
  • Exam (elaborations)
  • Questions & answers

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  • nur 390 exam 1 questions

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  • Chamberlain College Of Nursing
  • NR NUR390 (NUR390)
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NUR 390 Exam 1 Questions Minimum urine output? - 0.5ml/kg/hr How to calculate MAP? - Double diastolic + systolic / 3 Below 65 (or 70 in a healthy person) means the organs are not being properly perfused. This is a critical situation. Used to identify hypotension Nursing intervention for monitoring fluid volume - MAP I&Os Daily weights Lab data for monitoring fluid volume - Sodium, BUN, Hct signs/symptoms of fluid overload - Crackles, edema, hyponatremia (dilutional), bounding pulse, elevated BP/ MAP At risk for impaired gas exchange, tissue breakdown, activity intolerance, decreased body image. Hypovolemia lab values - BUN = High (hemoconcentration) Sodium = High (hemoconcentration) Hematocrit = Measures the ratio of red blood cells to fluid volume so it is high (hemoconcentration) Hypervolemia lab values - Albumin = Protein - We monitor this as fluid is leaking out of the capillary network and the client is presenting with edema or 3rd spacing BUN = Low (hemodilution) Sodium = Low (hemodilution) Hematocrit = Low (hemodilution) Priority intervention for excess fluid volume - Fluid volume excess resulting in crackles: give a diuretic. Priority assessment for fluid volume disturbance - Daily weights Client at risk for fluid volume deficit - High fever, heatstroke, DI, hemorrhage, GI losses from V/D, diuretics, dehydration, burns, pancreatitis How does low cardiac output affect the body? (LOCO MAN) - Neurological - Decreased LOC; Dizziness/Syncope; Anxiety; Sense of impending doom Cardiovascular - Chest pain/Tachycardia Respiratory - SOB/Tachypnea Gastrointestinal - N/V Kidneys - Low urine output or urine less than 0.5 ml/kg/hr Peripheral - Pale, cool, clammy Muscles - Weakness/Fatigue Potential complications for fluid volume deficit - Hypovolemic shock and risk for falls (orthostatic hypotension); low cardiac output Potential complications for fluid volume excess - Pulmonary edema, ascites, heart failure Hyperkalemia: Causes and protocol - Cause: Impaired renal function, acidosis (DKA), potassium sparing diuretics, potassium, IV fluids Protocol: 1. IV REGULAR insulin and a beta -adrenergic agonist to push potassium back into the cells. Then D50% so that you don't kill the client from the IV insulin. 2. Kayexalate given orally to bind to potassium in the bowel and eliminate it by stimulating bowel movement. 3. IV calcium gluconate to stabilize the cardiac membranes and protect from arrhythmias. Hypokalemia: Causes and protocol - Cause: Excessive diuresis with loop diuretic; clients who are receiving IV insulin for treatment of DKA and alkalosis. Protocol: Potassium replacement.

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