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Questions and Answers
What minimum urine output (mL/Kg/hr) indicates adequate fluid balance in a patient, according to the evaluation criteria for fluid volume status?
What minimum urine output (mL/Kg/hr) indicates adequate fluid balance in a patient, according to the evaluation criteria for fluid volume status?
Which assessment finding is indicative of fluid volume excess?
Which assessment finding is indicative of fluid volume excess?
A patient with heart failure is at risk for fluid volume excess due to which impaired regulatory mechanism?
A patient with heart failure is at risk for fluid volume excess due to which impaired regulatory mechanism?
Which laboratory finding would the nurse monitor closely in a patient with fluid volume excess?
Which laboratory finding would the nurse monitor closely in a patient with fluid volume excess?
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A patient with fluid volume excess is prescribed Furosemide (Lasix). Which nursing intervention is most important when administering this medication?
A patient with fluid volume excess is prescribed Furosemide (Lasix). Which nursing intervention is most important when administering this medication?
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Which of the following is the primary goal when treating hyponatremia?
Which of the following is the primary goal when treating hyponatremia?
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What is the initial action a nurse should take when a patient presents with hypernatremia?
What is the initial action a nurse should take when a patient presents with hypernatremia?
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Which condition is least likely to contribute to hypochloremia?
Which condition is least likely to contribute to hypochloremia?
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A patient with a head injury is at risk for which electrolyte imbalance?
A patient with a head injury is at risk for which electrolyte imbalance?
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What is the primary focus when treating hyperchloremia?
What is the primary focus when treating hyperchloremia?
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Which of the following is the most critical nursing intervention for a patient with a potassium imbalance?
Which of the following is the most critical nursing intervention for a patient with a potassium imbalance?
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What is the best approach for a nurse to take when reviewing a patient's electrolyte imbalances?
What is the best approach for a nurse to take when reviewing a patient's electrolyte imbalances?
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Potassium is predominantly located in which area?
Potassium is predominantly located in which area?
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Why is it essential to recognize cues for potassium imbalances?
Why is it essential to recognize cues for potassium imbalances?
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Which intervention is contraindicated when administering intravenous potassium?
Which intervention is contraindicated when administering intravenous potassium?
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What is the primary function of the kidneys in fluid and electrolyte balance?
What is the primary function of the kidneys in fluid and electrolyte balance?
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Which hormone is primarily responsible for promoting fluid retention in the body?
Which hormone is primarily responsible for promoting fluid retention in the body?
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How do the lungs contribute to homeostasis in the context of fluid balance?
How do the lungs contribute to homeostasis in the context of fluid balance?
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What is a primary characteristic of hypo/hyper electrolytes?
What is a primary characteristic of hypo/hyper electrolytes?
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Which of the following systems is involved in the regulation of fluid balance?
Which of the following systems is involved in the regulation of fluid balance?
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What is the role of the pituitary gland in fluid balance?
What is the role of the pituitary gland in fluid balance?
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Which of the following best describes homeostasis?
Which of the following best describes homeostasis?
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What clinical outcome involves applying inter-professional collaboration principles?
What clinical outcome involves applying inter-professional collaboration principles?
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What is the primary effect of increased ADH in the kidneys?
What is the primary effect of increased ADH in the kidneys?
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Which of the following best describes osmolality?
Which of the following best describes osmolality?
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What is typically referred to when discussing tonicity?
What is typically referred to when discussing tonicity?
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Which of the following factors can lead to fluid volume deficit?
Which of the following factors can lead to fluid volume deficit?
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How does osmotic movement related to tonicity primarily occur?
How does osmotic movement related to tonicity primarily occur?
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What is a key indicator of fluid intake exceeding output?
What is a key indicator of fluid intake exceeding output?
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What should be monitored in laboratory tests for electrolyte balances?
What should be monitored in laboratory tests for electrolyte balances?
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Which nursing diagnosis is associated with hyponatremia?
Which nursing diagnosis is associated with hyponatremia?
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Which of the following is NOT a common sign or symptom of fluid volume deficit?
Which of the following is NOT a common sign or symptom of fluid volume deficit?
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How is sodium primarily regulated in the body?
How is sodium primarily regulated in the body?
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Which clinical manifestation may suggest fluid volume excess (FVE)?
Which clinical manifestation may suggest fluid volume excess (FVE)?
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What is an important consideration when assessing older adults for signs of fluid volume deficit?
What is an important consideration when assessing older adults for signs of fluid volume deficit?
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What is a critical sign of hypokalemia that must be monitored?
What is a critical sign of hypokalemia that must be monitored?
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When developing a nursing diagnosis for a patient with fluid volume deficit, which component is correctly identified as part of the PES format?
When developing a nursing diagnosis for a patient with fluid volume deficit, which component is correctly identified as part of the PES format?
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Which action is essential for a nurse to take after determining the most appropriate IV solution for a patient?
Which action is essential for a nurse to take after determining the most appropriate IV solution for a patient?
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What educational point should be emphasized for a client at risk for fluid volume excess?
What educational point should be emphasized for a client at risk for fluid volume excess?
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What is the goal of implementing fluid replacement for a patient with fluid volume deficit?
What is the goal of implementing fluid replacement for a patient with fluid volume deficit?
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Which statement correctly describes the relationship between sodium and chloride imbalances?
Which statement correctly describes the relationship between sodium and chloride imbalances?
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Flashcards
Fluid Volume Deficit
Fluid Volume Deficit
A decreased amount of fluid in the body affecting physiological functions.
Fluid Volume Excess
Fluid Volume Excess
An increased amount of fluid in the body possibly leading to hypertension.
Electrolyte Imbalance
Electrolyte Imbalance
A disturbance in the level of electrolytes in the body, affecting various functions.
Homeostasis
Homeostasis
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Kidneys' Role
Kidneys' Role
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ADH (Antidiuretic Hormone)
ADH (Antidiuretic Hormone)
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Cardiovascular System
Cardiovascular System
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Pituitary Gland
Pituitary Gland
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Assessment Parameters
Assessment Parameters
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Nursing Diagnosis PES format
Nursing Diagnosis PES format
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Collaboration in Care
Collaboration in Care
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Gerontologic Considerations
Gerontologic Considerations
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Urine Output Evaluation
Urine Output Evaluation
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Fluid Volume Excess Causes
Fluid Volume Excess Causes
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Assessment Signs
Assessment Signs
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Nursing Diagnosis Example
Nursing Diagnosis Example
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Loop Diuretics
Loop Diuretics
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Osmosis
Osmosis
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Osmolality
Osmolality
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Tonicity
Tonicity
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Urine Output
Urine Output
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Normal Vital Signs
Normal Vital Signs
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Physical Assessment
Physical Assessment
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Laboratory Tests
Laboratory Tests
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Prevent Complications
Prevent Complications
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Sodium Imbalance
Sodium Imbalance
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Hyponatremia
Hyponatremia
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Hypernatremia
Hypernatremia
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Chloride Function
Chloride Function
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Hypochloremia
Hypochloremia
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Hyperchloremia
Hyperchloremia
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Potassium (K+) Balance
Potassium (K+) Balance
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Hypokalemia
Hypokalemia
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Hyperkalemia
Hyperkalemia
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Sodium-Potassium Pump
Sodium-Potassium Pump
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Nursing Intervention for K+ Imbalance
Nursing Intervention for K+ Imbalance
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Study Notes
Care for the Person with Basic Fluid and Electrolyte Needs
- Basic Fluid & Electrolyte Health Needs: This is a topic about caring for patients with basic fluid and electrolyte needs.
- Exemplars and NCLEX Client Needs: Exemplars for fluids include fluid volume deficit, fluid excess, and electrolyte imbalances like hypo/hyper-sodium, chloride, and potassium. These are categorized under physiological integrity, physiological adaptation, basic care, and comfort. Other categories include potential pharmacological and parenteral therapies, safe and effective care environment, management of care, safety and infection control, health promotion, and psychosocial integrity.
- Curriculum Threads: Clinical judgment, communication, quality improvement, health outcomes, legal/ethical collaboration, evidence-based practice, nursing process, and informatics are key curriculum threads.
- Course Outcomes: Four main outcomes include applying clinical reasoning for patient-centered care, applying interprofessional collaboration, implementing the nursing process to achieve patient outcomes, and demonstrating professional core values.
- Homeostasis: Kidneys maintain fluid and electrolyte balance, retaining and excreting liquids and electrolytes in response to hormones like aldosterone and ADH. Cardiovascular system circulates blood to kidneys, producing urine. Lungs maintain balance through insensible fluid loss and regulating CO2 affecting acid-base. Pituitary regulates fluids and electrolytes via ADH, increasing reabsorption for fluid retention.
- Pathophysiology of Fluid Imbalance: Key aspects are osmosis—fluid movement from low concentration to high, osmolality—osmotic pressure relating to solute/kg solvent, and osmolarity—osmotic pressure relating to solute/L of solvent.
- Tonicity: The ability of a solution to cause osmotic water movement. Hypotonic solutions cause movement into cells, while hypertonic solutions cause it out. Isotonic solutions have similar concentrations, causing no net movement.
- Fluid Volume Deficit (FVD): Causes include inadequate replacement, poor oral intake, certain medical conditions (CVA, dementia), inadequate IV fluids, and excessive losses (GI, vomiting, diarrhea, or other situations).
- Nursing Process & Clinical Judgment: The student must learn how to assess patients, discover clues regarding the patient's condition, analyze their findings to formulate a hypothesis, and how to then develop a conclusion based on the gathered evidence.
- Assessment for FVD: Blood pressure (orthostatic), heart rate (rapid thread pulse), respirations, urine output and specific gravity are important. Also important is assessment of mental status, skin color and turgor, capillary refill, weight, input and output, serum electrolytes, increased thirst, and cool clammy skin. General Considerations for geriatric patients include that skin turgor and thirst drive are not reliable indicators for older adults over 65.
- Nursing Diagnosis & Planning: PES format (problem, etiology, signs/symptoms) is used to formulate the plan of care related to type of dehydration and required safety measures to achieve health outcomes.
- Implementation and Taking Action for FVD: Minimize fluid loss, use oral/IV fluids, and monitor complications. Important considerations include the tonicity of fluids provided (isotonic, hypotonic, hypertonic). The use of various fluids should also consider collaboration with healthcare providers to determine appropriate treatment for patients.
- Evaluation of Outcomes: Monitor fluid intake and output, vital signs (BP, HR, RR), physical assessment findings (edema, lung sounds, mental status), electrolyte levels, and complications.
- Fluid Volume Excess (FVE): Causes include impaired regulatory mechanisms, renal failure, heart/liver failure, high sodium intake (oral or IV), increased cortisol, prolonged steroid therapy, severe stress, and hyperaldosteronism.
- Assessment for FVE: Important features include vital signs (BP, HR, RR), physical assessment (edema, lung sounds, weight), laboratory tests (electrolytes, ABG), and ongoing monitoring of potential complications.
- Sodium and Chloride Imbalance: Sodium range is 135-145 mEq/L. Chloride range is 96-106 mEq/L. This section addresses the control, causes, and treatment for imbalances of these electrolytes.
- Potassium Imbalance: Potassium is a major intracellular electrolyte (98% inside cells) and thus crucial for neuromuscular and cardiac function. It is regulated by the sodium-potassium pump. Minor imbalances can impact health. Considerations include signs, causing factors (medications and other issues), and assessment methods to evaluate these imbalances.
- Hypokalemia and Hyperkalemia: The causes and symptoms of low and high potassium are addressed with emphasis on their detrimental effects on other body systems.
- Nursing Management: Understanding and managing fluid and electrolyte imbalances in the clinical setting is a key topic. The role of safety and potential psychosocial implications that may affect care are also addressed.
- Diverse client needs and considerations in care: How diversity affects care for the person is a key topic.
- Evaluation of outcomes: The evaluation of outcomes for fluid, electrolytes, and their related imbalances are explained. This includes monitoring serum electrolytes, ABGs, input and output, vital signs, and assessing for neurologic issues, always maintaining safety of the patient.
Additional Topics (from fragmented text)
- Nursing Diagnosis, Planning, Implementation, Evaluation, and Generate Solutions are highlighted as important parts of patient care
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Description
Test your knowledge on fluid balance and electrolyte management in patients. This quiz covers various conditions, nursing interventions, and laboratory findings related to fluid volume status. Ideal for nursing students and healthcare professionals.