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FND 1 Final Exam Kirkwood Community College PNN 228
UPDATED ACTUAL and Correct Answers
Question: if you are walking in the desert with an empty water bottle, the amount of ADH secreted would most likely be...
Answer: ADH would increase to retain fluid
Question: when a person's blood pressure drops, the kidneys respond by...
Answer: the kidneys secrete renin
Question: fluids shifts at the capillary level are r/t hydrostatic pressure differences between the...
Answer: venous and arterial ends of capillaries -solute that moves from high concentration to low concentration
Question: a person has been hiking in the desert all day, the electrolyte imbalance you could expect is... a person has decreased their salt intake and is drinking large amounts of water per day to lose weight, the electrolyte imbalance you could expect is...
Answer: hypernatremia hyponatremia
Question: what happens to the concentration of sodium if there's an increased ADH?
Answer: the concentration of sodium will decrease
Question: what happens to the concentration of sodium if there's an increase in aldosterone? what's the response of aldosterone if a patient's BP is decreased? what fluid shift would occur with a low serum sodium
level? what fluid shift would happen with a high serum sodium level?
Answer: aldosterone increases to increase the BP shifts to intracellular (cells swell), extracellular fluid becomes hyptonic extracellular (cell shrivels), fluid becomes hypertonic
Question: when would the RN expect the HCP to order an isotonic fluid?
Answer: -for hypovolemia (fluid volume deficit) -d/t dehydration -restores fluid without a shift in the cell
Question: when would the RN expect the HCP to order a hypertonic fluid? when would the RN expect the HCP to order a hypotonic fluid? if someone had a poor intake of protein the nruse would expect their BP to be...
Answer: -severe hyponatremia (low blood sodium) -draws fluid out of cells and into the bloodstream -severe intracellular dehydration -hypernatremia -shifts fluid from blood and into cells to rehydrate them -low BP -d/t low protein in blood -water shifts out of the cell and into the tissues, which can lead to edema -edema = low BP
- ex: proteins (-), phosphate (-), potassium (+), magnesium (+)
- ex: chloride (-), bicarbonate (-), sodium (+), calcium (+) 2.) converts angiosinogen → angiotensin I 3.) ACE enzyme converts angiotensin I → angiotensin II (a vasoconstrictor) 4.) angiotensin II stimulates aldosterone release from adrenal glands
assesments:
- lung sounds, peripheral edema
- weight and I&O
- mental status (may show confusion)
- pitting edema
- jugular vein distention
- weight gain
- ↑ BP
- ↑ HR
- ↑ UA output interventions: -restrict fluids and sodium if prescribed
- elevate head of bed for breathing
- administer diuretics if ordered
- monitor respiratory status
- dehydration (loss of more water than sodium)
- diabetes insipidus
- excess salt intake or IV saline
- fever, sweating
- excessive water intake (or hypotonic fluids)
- heart failure, renal failure
- SIADH (syndrome of inappropriate ADH)
- diuretics
- confusion, restlessness
- muscle twitching or weakness
- excess water loss, diarrhea
- medications
- NPO
- ↑ temp
- ↑ HR
- may have orthostatic hypotension
Question: a patient's urine output is less than 50 mL per hour, what is the first step the nurse should take?
Answer: notify the HCP
- 5% dextrose in 0.45% saline
- 5% dextrose in 0.9% saline
- 10% dextrose in water
Question: the nurse is assessing the client who reports n/v and weakness, what findings are manifestations of a fluid volume deficit? a nurse is planning to care for a client who has fluid volume excess, what interventions should the nurse include in the pt's care plan? the nurse is assessing two clients, sort the findings into manifestations associated with either FVD or FVE: 1.) bounding pulse 2.) sunken eyeballs 3.) crackles in lungs 4.) poor skin turgor 5.) fever 6.) distended neck veins a nurse is assessing a client who has hypovolemia d/t vomiting and diarrhea, the nurse should expect what findings?
Answer:
- urine specific gravity (concentrated)
- heart rate (tachy)
- temperature (elevated)
- place the client in a semi-fowler's position (reduce risk for tissue breakdown)
- moinitor client's breath sounds (risk for pulmonary edema)
- assess the client for peripheral edema 1.) bounding pulse = FVE 2.) sunken eyeballs = FVD 3.) crackles in lungs = FVE 4.) poor skin turgor = FVD 5.) fever = FVE 6.) distended neck veins = FVD
- hypothermia
- orthostatic hypotension
- ↓ skin turgor
what is the priority nursing intervention for a patient with a pH 7.21, CO2 42, and HCO3 21? the nurse is caring for a patient with the following labs: Na 139, Ca 9.7, and K 2.9. what is an appropriate diet for this pt?
Answer: metabolic acidosis orthostatic hypotension obtain baseline BP chicken breast, spinach salad, and orange slices
Question: what is the priority nursing intervention for a patient with the following acid-base? pH 7.5, CO2 38, and HCO3 32... what is the priority nursing intervention for a patient with the following acid-base? pH 7.5, CO2 31, HCO3 29... what is the priority nursing intervention for a patient with the following acid-base? pH 7.25, CO2 51, HCO3 26... what are the initial expected findings for a patient with a serum sodium of 158?
Answer: raise the HOB initiate seizure precautions raise the HOB -thirst -dry mucous membranes -tachycardia -orthostatic hypotension
Question: what is the priority nursing assessment for a patient with a serum sodium of 132? what is the priority intervention for a patient with a serum sodium of 125? the nurse is caring for a patient with a serum calcium of 12, what is the priority nursing assessment? what is the priority nursing intervention for a patient with a serum calcium of 11? what are the signs and symptoms of a patient with a serum
calcium level of 8.2?
Answer: cerebral edema raise the HOB blood clots increase fluid intake -diarrhea -hyperactive bowel sounds -positive Chvostek's sign
Question: what are the clinical manifestations for a patient with a serum potassium level of 5.8? what is the expected acid-base imbalance for a patient with diabetes and the following vital signs: 92/51 and HR 119 a patient with anxiety is hyperventilating, which acid-base labs would the nurse expect? the nurse is caring for a patient with an albumin level of 2.7, what is the expected nursing assessment? what is the most important patient education for a patient with a potassium level of 6.1?
Answer: -cardiac arrythmias -hyperactive bowel sounds -diarrhea metabolic acidosis pH 7.5, CO2 32, and HCO3 26 -hypotension -peripheral edema instructions on how to assess their radial pulse for a full minute
