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NR 324 Exam 1 Questions with Correct Answer1
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NR 324 Exam 1 Questions with Correct Answer1
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NR 324 Exam 1 Questions with Correct AnswersWhat is the definition of fluid volume deficit? Correct Answer--
occurrence w/ abnormal loss of Extracellular fluid (ECF)
What can cause fluid volume deficit? Correct Answer-- inadequate fluid
intake
- abnormal loss of body fluids
- shift from ECF to ICF
What are some examples of abnormal fluid losses that can lead to Fluid
Volume deficit? Correct Answer-- Diarrhea
- Vomiting
- Hemorrhage
- Polyuria
What LOC changes are manifestations of ECF deficit? Correct Answer--
Restlessness
- Drowsiness
- Lethargy
- Confusion
- Dizziness
What integumentary manifestations occur with ECF deficit? Correct
Answer-- Cold clammy skin
,- Decreases skin turgor
- Dry mucous membranes
What cardiovascular manifestations occur with ECF deficit? Correct
Answer-- decreased capillary refill time
- Increase pulse rates
- Decrease CVP
- Postural hypotension
What does CVP stand for? Correct Answer-- Central venous pressure
What Respiratory manifestations occur with ECF deficit? Correct
Answer-- Increased Respiratory rate
What urinary manifestations occur with ECF deficit? Correct Answer--
Decreased urinary output (Anuria)
- Concentrated specific urinary gravity
What urinary specific gravity test results would indicate ECF deficit?
Correct Answer-- > 1.025
What are some important nursing management skills to implement with
ECF deficit and excess? Correct Answer-- Daily weight monitoring
- Input /output monitoring
- Vital signs monitoring
,What weight gain should a patient report to their HCP regarding Fluid
retention? Correct Answer-- increase in 1 Kg or 2.2 lbs
How much mL of water retention is retained with 1kg (2.2 lbs) increased
in weight? Correct Answer-- 1,000 mL (1L)
What should be instructed to patient when it comes to monitoring
weight? Correct Answer-- Weigh every day at the same time
- typically wear like clothing
- Use same calibrated scale
What should a nurse do prior to weighing a patient? Correct Answer--
remove excessive bedding
- empty all drainage bags
What is included in input documentation? Correct Answer-- Oral intake
- IV fluids
- Tube feedings
- Retained irrigation solutions
What is included in output documentation? Correct Answer-- Urine
- Excessive perspiration (estimated)
- Wound / tube drainage (estimated)
, - Vomitus
- Diarrhea
What should be noted about urine? Correct Answer-- amount of urine
- coloration of urine
- measure specific urinary gravity
What is considered to be diluted urine gravity? Correct Answer-- <
1.010
When should a nurse perform a cardiovascular assessment with ECF
deficit? Correct Answer-- PRN (ECF deficit Cardio)
`What causes the increased HR related to ECF volume deficit? Correct
Answer-- Due to Peripheral Vasoconstriction
What pulse force is associated with ECF volume deficit? Correct
Answer-- Weak / thready pulses (ECF deficit)
What should be implemented with a patient with ECF volume deficit?
Correct Answer-- Fall precautions should be implemented
What is a normal skin turgor test look like? Correct Answer-- Readily
moves and, when released rapidly returns to former position
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