NR 324- Exam 1 Fluid And Electrolytes And Respiratory (Latest 2024/2025)

NR 324- Exam 1 Fluid And Electrolytes And Respiratory a 21 year asthmatic who states "I am not getting air" - ✅ sit up, O2%, give O2 a 55 year old female with breast cancer treated with chemotherapy and radiation who becomes acutely SOB - ✅ need data, pain and distress, Pulmonary embolism or pleural effusion (absent breath sound, if dull pleural effusion) a 66 year old female with fever 101.0, productive cough and restlessness - ✅ check sputum, culture, check lungs for crackles, pneumonia a patients condition is described as progressing to hypoxemia, how would the nurse interpret this information - ✅ there is a abnormally low level of oxygen in the blood a pt with active TB contines to have positive sputum cultures after 6 months of treatment, she says she can't remember to take the medication all the time, what is the best action for the nurse to take - ✅ arrange for directly observed therapy by a responsible family member or public health nurse altered transport of oxygen - ✅ anemia and inadequate perfusion an 18 year old male who was thrown off his motor cycle and is holding the side of his chest, he is SOB with pulse ox of 88% - ✅ need lung sounds, pneumothorax aspiration pneumonia priority - ✅ heads up, positioning t the side aspiration pneumonia who is at risk - ✅ tube feedings, altered LOC, neurological impairments, impaired swallowing asthma CM - ✅ cough, increase mucus, sob, wheezing, prolonged expiration, increase in co2 retention, chest tightness, retractions, hypoxemia (tachycardia, restlessness, tachypnea) asthma is - ✅ reactive airway disease, induced by triggers, hypersensitivities, URI, exercise, air pollutants, respiratory infections and GERD and anxiety atelectasis - ✅ collapse of the alveoli, increases the risk for pneumonia, and affects many populations

atelectasis nursing management - ✅ use of incentive spirometer, watch for infections, cough, turn, deep breathe, ambulate bronchoscopy - ✅ aspirate, check CN 9 and 10 every 10 minutes after to make sure gag reflex comes back, NPO after procedure, calcium - ✅ controlled by the parathryroid hormone and calcitonin, bones store, regulated with moving in/out of bones which increases GI and renal absorption, calcitonin lowers ca by decreasaing GI absorption and increasing absorption causes of metabolic acidosis - ✅ low ph/low bicarbonate, diabetic ketoacidosis, shock, sepsis, severe diarrhea, and renal failure causes of metabolic alkalosis - ✅ high ph, high bicarb and severe vomiting, excessive GI suctioning, diuretics, and excessive NaHCO3 causes of respiratory acidosis - ✅ respiratory depression from anesthesia, overdose, increased intracranial pressure, airway obstruction from decreased alveolar capillary diffusion like pneumonia, COPD, ARDS, AND PE causes of respiratory alkalosis - ✅ high pH, low co2 and hyperventilation, initial stages of pulmonary emboli, hypoxia, fever, pregnancy, high altitudes, and anxiety chest drainage device - ✅ water to and forms a seal which allows air/fluid to move out but not back in, tidiling which is going up and down with inspiration is normal, has to be below the level of the lung clinical signs for hypocalcemia - ✅ chvostek sign (contraction of facial muscles that occur when lightly tapping on ear) and trousseau sign (carpal spasm bringing the index finger and thumb together when the BP cuff is inflated above systolic pressure) collaborative care of COPD - ✅ venturi mask or non-rebreather mask, selfmanagement education and smoking cessation, bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, and oxygen COPD CM - ✅ easily fatigued, frequent respiratory infections, use of accessory muscles to breathe, orthopenic, tripod position, cor pulmonale, thin in appearance, wheezing, pursed lip breathing, chronic cough, barrel chest, dyspnea prolonged expiratory time, increased sputum, and digital clubbing COPD risk factors - ✅ smoking, genetic factors, prolonged exposure to dust and chemicals, secondhand smoke, air pollution

COPD teaching - ✅ infection prevention, flu/pneumonia vaccines, avoid triggers, allergens, smoke/air pollutants, exercise and to increase quality of life CPAP therapy - ✅ potential life saving and changing option for the treatment of sleep apnea decreased Na is caused by dilution as a result of - ✅ excess water or increased Na loss decreased output causes - ✅ renal failure dehydration - ✅ loss of water alone without sodium, cell shrinks diagnostic testing for respiratory oxygenations - ✅ pulse ox, Allen's test to assess before ABG, x-ray excessive intake causes - ✅ rapid oral ingestion of water, infusions of D5%W hypotonic fluid at excess, massive replacement of water without NA fluid in lungs - ✅ crackles, then rhonchi which leads to secretions and then infections fluid overload increases from - ✅ heart failure, corticosteroid therapy, wound irrigations fluid volume deficit causes - ✅ water loss, perspiration, diabetes insipidus, osmotic diuresis, hemorrhage, GI losses like vomiting, NG suctioning, diarrhea, fistula drainage, overuse of diuretics, inadequate fluid intake, third space shifts, burns, intestinal obstruction fluid volume deficit nursing interventions - ✅ intake/output, cardiovascular changes, LOC changes, pupillary response, responsiveness, voluntary movement, patient safety, seizure precautions, fall precautions, daily weights, skin assessment for turgor/color/dryness, pitting edema, administer IV fluids fluid volume deficit population - ✅ elderly, profuse sweating, v/d, NG tubes, trauma r/t bleeding, pts NPO, AMS, surgical patients, laxativies, diruetics fluid volume deficit signs/symptoms - ✅ restlessness, drowsiness, lethargy, confusion, thirst, dry mucous membranes, decreased skin turgor, decreased cap refill, postural hypotension, increased pulse 120, decreased CVP, decreased urine output, concentrated urine, increased respiratory rate, weakness, dizziness, seizures, coma, decreased BP 86/50 fluid volume excess causes - ✅ heart failure, water intoxication, liver cirrhosis, SIADH, lung cancer, renal failure, primary polydipsia, long term use of cortiosteroids

fluid volume excess clinical manifestations - ✅ headache, JVD, increased weight, edema, ascites, elevated blood pressure, crackles in lungs, confusion, decreased urine specific gravity, pitting edema, high BP, presence of s3, tachycardia, bounding pulse, changes in LOC, seizures, low pulse ox (below 89%), seizures, coma, muscle spasms, dyspnea fluid volume excess nursing management - ✅ frequent respiratory assessments and LOC, watch for edema, cardiovascular checks, daily weights, fluid restriction, measure intake and output, decrease sodium intake, diuretics gas exchange - ✅ the process by which oxygen is transported to the cells and carbon dioxide is transported from the cells HCO3 - ✅ 22-26 mEq/L high pH - ✅ alkalosis hypercalcemia causes - ✅ results from malignancy, increased production of PTH, hyperparathyroidism, prolonged immobilization, vitamin d overdose, thiazide diuretics hypercalcemia signs/symptoms - ✅ painful bones, renal stones, abdominal groans like N/V, constipation, indigestion and psychiatric moans like lethargy, fatigue, memory loss, psychosis, depression hyperkalemia caused by - ✅ life threatening, impaired renal excretion of potassium, excess intake, metabolic acidosis and medications like beta blockers, dehydration hyperkalemia relates to - ✅ weakness of the muscles and reduced excitability of muscles such as hypoactive bowel sounds and hypoactive deep tendon reflexes hyperkalemia signs/symptoms (MURDER) - ✅ muscle cramps, urine abnormalities, respiratory distress, decreased cardiac contractility, EKG changes, and reflexes hypermagnesemia causes - ✅ renal dysfunction, use of antacids, use of laxatives like MOM, and Mag sulfate hypermagnesemia signs/symptoms - ✅ respiratory depression, lethargy, cardiac arrest, diminished deep tendon reflexes, flushed warm skin, decreased pulse, decreased BP, muscle weakness, dysphagia, N/V hypernatremia causes - ✅ sodium greater than 145, intake excessive, IV fluids (hypertonic Nacl, IV sodium bicarbonate), hypertonic tube feedings without water supplements, near-drowning in salt water, inadequate water intake (cog impaired),

excessive water loss (heatstroke, high fever), osmotic diuretic therapy, diarrhea, disease states like DI, primary hyperaldosteronism, cushing syndrome, uncontrolled diabetes mellitus hypernatremia nursing interventions - ✅ treat the cause, add water to balance sodium, or replace sodium and water, monitor I/O, urine specific gravity greater than 1.025, pulses, tachycardia, tachypnea, changes in sensorium, daily weights, skin turgor and mucous membranes hypernatremia; fluid volume deficit signs/symptoms - ✅ signs of thirst, fever, dry mucous membranes, hypotension, tachycardia, low jugular venous pressure and restlessness, weakness, change of LOC, thready pulses hyperphosphatemia - ✅ renal failure patients, diseases of endocrine system, fleets enema, sickle cell anemia hypertonic solutions - ✅ 3-5% NS, CHF, Hypervolvemia, edema, pull sodium in vasculature hypocalcemia causes - ✅ any condition decreasing serum calcium levels like cirrhosis, malnutrition, decreased production of PTH like hypoparathryoidism, loop diuretics, alkalosis, vitamin D deficiency hypocalcemia signs/symptoms (CATS) - ✅ convulsions, arrhythmias, tetany, stridor and spasms hypokalemia assessment - ✅ muscle weakness and cramps, life threatening if not treated, alkalosis on ABG, fatigue, depressed ST with a U wave, arrhythmias, thready pulse hypokalemia is caused by - ✅ increased excretion of potassium, N/V, sweating, diuretics, dialysis, increased insulin, alkalosis, tissue repair, increased epinephrine, lack of intake hypokalemia nursing interventions - ✅ watch for skeletal muscle weakness, most dangerous drug to administer, on IV pump no more than 10 mEq/hr, causes vein irritation, ice site, lidocaine, monitor, piggyback with normal saline, always on a pump, encourage intake from foods hypomagnesemia causes - ✅ inadequate intake (malnutrition, malabsorption), metabolic acidosis, alcoholism, malabsorption from inflammatory bowel diseases, excessive gastric drainage hypomagnesemia signs/symptoms - ✅ confusion, tremors, seizures, hyperactive deep tendon reflexes, insomnia, increased pulse, increased BP, muscle cramps

hyponatremia causes - ✅ sodium is less than 135 mEq/L, vomiting, diuretics, gastrointestinal suctioning, diarrhea, inadequate salt intake, fluid shift from the ICF to the ECF by hypertonic solutions which leads to dilutional hyponatremia hyponatremia interventions - ✅ administer hypertonic solutions with known Na value, monitor patients lungs sounds, administer isotonic solutions with unknown sodium level, report LOC changes, fluid restriction if caused by too much water hyponatremia signs and symptoms - ✅ cell swells, lethargy, headache, confusion, apprehension, seizures, and coma, change in LOC, muscle weakness, stupor, tendon reflexes decreases hyposhoshatemia - ✅ rare disorder, malnourished, malabsorption, hypoventilation like respiratory alkalosis hypotonic solution - ✅ 0.45 NS, D5W, dehydrated and hypovolemic, moves to cells, swells, neurologically comprised impaired elimination of carbon dioxide leads to - ✅ respiratory acidosis impaired oxygenation leads to - ✅ ischemia intervention for hypomagnesemia - ✅ administer MG oral or IV, increase food intake isotonic solution - ✅ 0.9% NS, lactated ringers, dehydrated low pH - ✅ acidic lung sounds - ✅ crackles (high pitched, heard during inspiration, discontinuous), rhonchi (rumbling, coarse sounds, like a snore, may clear with coughing/suctioning, continuous), and wheeze (musical noise, continuous) magnesium normal range - ✅ 1.3-2.1 mEq/L for adults management of asthma - ✅ adrenergic (beta 2 agonists/albuterol), steroids, theophylline, hydration, mask of o2 and anticholinergic metabolic acidosis - ✅ low ph, normal co2 and low bicarbonate metabolic acidosis nursing management - ✅ BUN, creatinine, hemoglobin/hematocrit levels, monitor hydration, turn/cough/deep breathe, ABG's, check K, Ca usually goes down, weights, vitals

metabolic acidosis signs/symptoms - ✅ compensatory hyperventilation (kussmaul respirations), headache, decreased BP, hyperkalemia, muscle twitching, warm/flushed skin, N/D/V, changes in LOC, metabolic alkalosis - ✅ high ph, normal co2, and high hco3 metabolic alkalosis nursing management - ✅ monitor ECG's, ABG's for pH, K, Ca levels, LOC checks for tetany, tremors, muscle cramps, tingling, metabolic alkalosis signs/symptoms - ✅ restlessness (lethargy), confusion, dizzy, irritable, dysrhythmias, compensatory hypoventilation, N/V/D, tremors, muscle cramps, tingling of fingers and toes, dehydration Narcan - ✅ reverses CO2 toxicity like in drug overdoses narrowed airways - ✅ from asthma, infection, inflammation, pneumonia and sounds like a wheeze or whistle normal calcium levels - ✅ 8-10 nurse can give the most oxygen using - ✅ non-rebreather mask for severe hypoxia nurse specific for TB - ✅ public health nurse who does direct observed therapy at sites nursing care of a tracheostomy - ✅ suction, clear sections, patient comfort if can ease at all possible, do not remove ties unless doctor order nursing care of patient with chest tube - ✅ check drainage device, site secure, sutured in, skin assessment, vitals, pan nursing care of patient with impaired gas exchange - ✅ life the HOB (open airway), give oxygen, asculate, look for sputem, chest x-ray, and give antibiotics also be aware for signs of distress nursing intervention for hypermagnesemia - ✅ focus on prevention, decrease intake of foods like bananas, oranges, peanut butter, chocolate nursing interventions for impaired ventilation - ✅ ventilating and oxygenating nursing management for pneumonia - ✅ ambulate, incentive spirometer, cough, turn and deep breathe

nursing management of hyperkalemia - ✅ check for muscle weakness, administer diuretics, monitor renal and respiratory status, restricted diet, increase fluid intake, administer insulin-kayexalate, dialysis, monitor ECG, monitor blood sugar nursing management of hypernatremia - ✅ administer hypotonic solution if na known, administer isotonic solution if na is not known, if corrected too quickly can cause cerebral edema nursing management of hypocalcemia - ✅ monitor for dysrhythmias, diet high in calcium and vitamin D, assess for discomfort, IV site, IV preparations, oral supplements nursing management of hyponatremia - ✅ I/O, check for bounding pulses, bulging neck veins, BP changes, signs of cerebral edema, daily weights, pitting edema with fluid excess, daily weights and goal is to restore na and water balance and prevent complications of cerebral edema Nursing management of respiratory acidosis - ✅ ventilator, arterial blood gas, low-dose oxygen in chronic conditions, high-dose oxygen in acute hypoxia with acidosis, I/O, promote the release of CO2, turn/cough/deep breathe, assume semi-high fowlers position, clear respiratory secretions, colors of skin, mucous membranes nursing management of respiratory alkalosis - ✅ kidneys retain H+ ions, use a rebreather mask or paper bag, sedatives, monitor respiratory rate/depth, tachycardia, low BP, serum K+ levels/ECG levels, hydration status I/O, check for toxicities obstructive sleep apnea (OSA) risk factors - ✅ hypertension, diabetes, heart disease, driving and work related accidents and strokes OSA CM - ✅ snoring, excessive daytime sleepiness, pauses in breathing while sleeping, and decreased sex drive, having no neck, overweight OSA nursing management - ✅ sit up, oxygen, sleep study, educate on diet/lifestyle pa CO2 - ✅ 35-45 mm Hg pain medications - ✅ depress respiratory system paO2 - ✅ 80-100 mm Hg peak flow meter - ✅ establishes baseline and assesses severity of symptoms for patient, red with peak flow less than 50% call 911, yellow with peak flow 50-80% give medication, and green with peak flow greater than 80% is good pH - ✅ 7.35-7.45

pharmacologic treatment options for asthma - ✅ reliever which are short acting bronchodilators (quick) and controllers which are daily medications taken on long term basis used for controlling persistent asthma and includes anti-inflammatory agents and long acting bronchodilators phosphorus - ✅ essential to muscle function, RBC, and nervous system, found in bones and teeth pleural effusion is, assessment and population - ✅ fluid build up in lungs, assess for unequal lung expansion, dull, the degree of patient distress depends on the degree of effusion, no sound on lung, fluid volume excess and cancer patients pleural effusion nursing management - ✅ thoracentesis pneumonia CM - ✅ productive cough with yellow, blood-streaked sputum, malaise, fever, chills, tachycardia, tachypnea, dyspnea, pleural pain, respiratory distress, decreased breath sounds pneumonia is - ✅ obstruction of bronchioles, decreased gas exchange, and increase exudate, hospital acquired or community acquired, opportunistic pneumonia orders - ✅ sputum culture, chest x-ray and ABG's pneumonia population - ✅ over age 65, respiratory infections, COPD, bedridden patients, immunocomprised and smoking pneumothorax causes (who is at risk) - ✅ trauma, gun shot, quick growing boys, ruptured BLEB from COPD, thoracentesis, secondary infection pneumothorax CM - ✅ unequal expansion, decreased breath sounds, pleural pain, dyspnea, anxiety, tachycardia pneumothorax diagnosed by - ✅ chest x-ray, ABG pneumothorax Immediate nursing management - ✅ check for unequal expansion, listen for no sound, feel if bouncy (air), chest tube (equalizes pressure), oxygen pneumothorax is - ✅ air in the pleural cavity, resulting in lung collapse populations at risk - ✅ infants/young children, older adult (posture which leads to infection, not moving, neurological impairment), tobacco use, risk for aspiration, bed rest and immobility, immunosuppression, and chronic disease

populations for TB - ✅ homeless, immunocompromised, immigrants, Asians potassium imbalances - ✅ heart contractions and ECG will guide plan of care pulmonary embolus CM - ✅ sudden sharp chest pain, bloody sputum, respiratory distress, tachypnea (decreased co2), hypoxia (decreased o2), dyspnea, tachycardia pulmonary embolus nursing management - ✅ thrombolytic therapy remember to separate the lines/do not mix, blood thinners, and removing the embolus pulmonary embolus risk factors - ✅ immobility, obesity, DVT, postoperative, decreased pco2, decreased oxygen, increase pH, venous stasis recent tracheostomy doctor orders - ✅ do not change it, always have TT (new trach kit near patient) rescue inhaler - ✅ short acting, beta 2 agonist and can increase time for patient respiratory acidosis - ✅ low pH, high co2, normal bicarbonate respiratory alkalosis - ✅ high pH, low co2 and normal bicarbonate signs/symptoms of hypokalemia (A SIC WALT) - ✅ alkalosis, shallow respirations, irritability, confusion and drownsiness, weakness and fatigue, arrhythmias, lethargy, thready pulse signs/symptoms of respiratory acidosis - ✅ hypoventilation (hypoxia), rapid, shallow respirations, decrease in BP, skin/mucous pale to cyanotic, headache, hyperkalemia, dysrhythmias, drowsiness, dizziness, disorientation, muscle weakness, hyperreflexia signs/symptoms of respiratory alkalosis - ✅ seizures, deep/rapid breathing, hyperventilation, tachycardia, decrease BP, hypokalemia, numbness/tingling in extremities, lethargy/confusion, light headedness, N/V tension pneumothorax assessment - ✅ tracheal deviation when the trachea goes to the unaffected side from chest tube disrupting airflow leading to air build up leads to increased pressure on affected side and severe dyspnea, call for help the client with COPD is most likely to experience which acid-base imbalance - ✅ respiratory acidosis the nurse anticipates the client with which condition would be most at risk to develop hyperkalemia - ✅ chronic renal failure

the nurse assigned to a client with hyponatremia would conclude that which of the following factors probably contributed to this electrolyte imbalance - ✅ fluid retention and heart failure the nurse is assessing a client who has hypocalcaemia, which of the following clinical finding would the nurse expect to observe - ✅ twitching, hyperactivity of muscles, positive trousseau's sign the nurse is assigned to care for a group of clients, the nurse determines that which client is at risk for fluid volume deficit - ✅ client with a colostomy the nurse is educating the client who has a magnesium level of 1.2 mEq/L, what information is most important for the nurse to include in discussions with the client - ✅ hypomagnesemia, diet counseling the nurse provides discharge instructions to a pt. who has hospitalized for pneumonia, which statement indicated a good understanding of the instructions - ✅ I will continue to do the deep breathing and coughing exercises at home the nurse provides instructions for a client with hypokalemia about foods that are high in potassium and tells the client to consume which foods - ✅ raisins, potatoes, cantaloupe, strawberries the PCP prescribes an intravenous infusion containing potassium, which nursing intervention is essential before administering the solution for the client - ✅ measure urinary output thoracentesis - ✅ outside and in, inserting the needle between the ribs, in the space around the lung and not into the lung, assess for composition of pneumothorax to determine whether a tension pneumothorax is developing in a pt with chest trauma, for what does the nurse assess the patient - ✅ severe respiratory distress and tracheal deviation tracheostomy is - ✅ an artificial airway tuberculosis CM - ✅ bloody sputum, night sweats, progressive fatigue, malaise, anorexia, weight loss, chronic cough (productive), pleuitic chest pain, low grade temperature tuberculosis is diagnosed by - ✅ positive sputum studies (3 specimens collected on different days), TB skin test, chest x-ray tuberculosis nursing cautions - ✅ airborne precautions, N95 mask

tuberculosis treatment - ✅ medications that are 6-12 months, decreased activity, isolation until negative sputum, frequently out patient basis two days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety, what is the first action that the nurse should take - ✅ raise the head of bed two phases of hyponatremia - ✅ 1 is too much volume, so decrease in sodium to correct give diuretic and 2 is loss of sodium from other sources to correct on individual basis types of impaired ventilation - ✅ narrowed airways, obstructed airways, in inadequate muscle/nerve function, poor gas diffusion in alveoli what goes up in acidosis - ✅ potassium what impacts gas exchange - ✅ diseases what is a compensatory mechanism for metabolic alkalosis - ✅ decreased respiratory rate and depth to retain CO2 and kidney excretion of bicarbonate what is hyperkalemia frequently associated with - ✅ metabolic acidosis what occurs with patients who have hypercalcemia - ✅ pathologic fractures when calcium is increased - ✅ phosphorus is decreased when phosphorus is increased - ✅ calcium is decreased when should the nurse check for leaks in the chest tube and pleural drainage system ✅ there is continuous bubbling in the water-seal chamber which method of oxygen administration is the safest system to use for a patient with exacerbation of COPD - ✅ venture mask which of the follow interventions does the nurse complete when caring for a client admitted with a sodium level of 152 mEq/L - ✅ observe and prepare for possible seizures