NUR242 / NUR 242 Exam 4 Galen
Study Notes + Study Guide Questions
Medical-Surgical Nursing Concepts
Table of Contents
NUR 242 Exam 4 Study Notes………………………………… 01
NUR 242 Exam 4 Study Guide Questions……………………28
1. Risk factors: fluid overload: •Excessive fluid replacement
•Kidney failure (late phase)
•Heart failure
•Long term corticosteroid therapy
•Syndrome of inappropriate antidiuretic hormone (SIADH)
•Water
intoxication
Diabetes Insipidus
Hypernatremia
,2. S/S: fluid overload: tachycardia, bounding pulse, HTN, decrease pulse pressure,
JVD, weight gain
increase and shallow resp; SOB, crackles lung sounds
pitting edema, skin pale/cool
HA, visual disturbance, muscle weakness, paresthesia
increase motility, enlarged liver
3. Assessment: fluid overload: •Assess risk r/t age and diagnosis, history
(over- hydration, CHF, kidney disease)
•Assess vital signs: bounding tachycardia, HTN, dysrhythmias, tachypnea
•Assess lung sounds (crackles), weight, LOC, JVD
•electrolytes imbalance and signs and symptoms
skin/extremities/abdomen/sacrum area for edema
•Assess perfusion: edema, peripheral/central pulses, capillary refill, skin color, temp,
sensory and motor function
urine output
4. Labs: fluid overload: •Serum osmolality (285-295 mOsm/kg)
•Decrease found in overhydration < 285; and < 265 is critical finding
•CBC
•Decrease hemoglobin and hematocrit
• < BUN
•Electrolytes
• < sodium
,•Urine specific gravity Decrease < 1.005
5. Interventions: fluid overload: •Goal: reduce excess body fluids, promote
de- sired elimination
-Monitor skin also around mask/nasal cannula, position changes,
•Manage underlying cause
•Restrict dietary sodium intake
•Monitor I/O - daily wt. >3lb gain/week or 2lbgain/24hrs: call CP
•Administer diuretic
-ECG patterns
•Monitor client's s/s and electrolytes values
•Restrict oral and other fluid intake as prescribed
6. Complications: fluid overload: •Isotonic overhydration
•HF and pulmonary edema
•Seizure
•Coma
7. Medications: fluid overload: Furosemide
Mannitol
8. S/S: dehydration: •Vital signs: Increased: HR, BP, RR
hyperthermia, ST, thread pulse, hypotension, decrease CVP
<skin turgor, dry/scaly, dry mucous membraines
•Neuromusculoskeletal: Dizziness, syncope, confusion, weakness, fatigue
, •GI: thirst, dry furrowed tongue, N/V, anorexia, weight loss
< urinary outpt
•Other signs: Diminish capillary refill, cool clammy skin, diaphoresis, sunken eye-
balls, flat neck vein
9. Assessment: dehydration: •Assess for condition leading to dehydration: diar-
rhea, poor intake, vigorous exercise, vomiting, polyuria, fluid losses (burns, trauma)
clients with drains/NG tube, burns/fluid shifts, overuse of diuretic
10. Labs: dehydration: •Serum electrolytes (hypernatremia)
•Increased serum osmolality normal 275- 295 mOsm/kg; elevated > 295 found in
dehydration; > 320 is critical finding
•CBC elevated H/H
•Elevated urine specific gravity > 1.030
•Increased BUN
11. Interventions: dehydration: •Goal of interventions: replace fluid and elec-
trolytes to achieve homeostasis
•Closely monitor status and rehydration, avoid overcorrection
•Monitor I/O and weight
•Identify and manage cause- diarrhea, vomiting, blood loss, poor intake
Monitor fluid overload JVD sitting up, dependent edema, assess IV site
•Maintain at least 1500mL/day or 500mL more than urinary output-know s/s of
