exam 3 INTRO

left ventricle

pumps blood through aorta to the whole body, high pressure thick walls

right atrium

receives deoxygenated blood from lungs via pulmonary veins

effects of aging

reduced CV, renal, resp. function, reduced muscle mass, increased use of medication effect, loss of thirst mechanism, atypical assess. finding

extracellular fluid

20 % of body weight

no perfusion

infarction/necrosis

Nursing Implications: Secondary Interventions

BP screenings, lipid screenings, monitor edema and weight

9. The nurse is assessing a patient with suspected hypomagnesemia. Which finding during the nursing assessment would be consistent with this condition?

Hyperactive deep tendon reflexes

8. A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care?

Infuse hypotonic IV fluids

coronary arteries

Provide oxygen-rich blood to cardiac musculature during diastole

1. The student nurse studying fluid and electrolyte balance learns that which of the following is a function of water?

To provide a medium for transporting wastes from cells and nutrients to cells.

hyperkalemia

abd. cramp, flaccid paralysis, slow irregular pulse, low BP, cardiac arrest dietary restriction, regular insulin, salt substitutes

arteries

carry oxygenated blood

6. A client who is postoperative is receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload?

dyspnea

manifestations of FVE

edema, DVT, crackles, tachy, inc BP, weight gain

hypokalemia

fatigue, muscle weakness, parathesia, pulse weak admin. K, monitor serum, dietary counseling

lean muscle

high water content

impaired perfusion

ischemia

third spacing

leakage from blood vessels into tissue spaces

4. A nurse is admitting a client who has a serum calcium level of 12.3 mg/dl. Which of the following findings should the nurse expect during the initial assessment?

lethargy

right and left ventricles

low chambers, pumping chambers

adipose tissue

low water content

filtration

movement of water, solutes occur from area of high hydrostatic pressure to area of low

SA node

natural pacemaker

hypomagnesemia

paresthesia, chvostek's sign +, trousseau's sign, LOC, seizure seizure prec. dietary replace.

Ejection Fraction

percentage of volume ejected w/every beat

hypocalcemia

peripheral numbness, trousseau's sign, chvostek's sign, irritable, tremors assess. neuro changes. prepare for resuscitation, seizure prec. (trach)

active transport

physiologic pump that moves fluid from area of lower concentration of one of higher

sodium

pools in ECF

potassium

pools in ICF

right and left atria

upper chambers, low pressure, thin walled, receives blood

sensible output ex.

urination, defecation, wound drainage

osmosis

water moves from an area of low solute concentration to area of high

hypermagnesemia

weakness, lethargy, low BP, brady, resp. arrest dialysis, prepare for resusc.

insensible output ex.

skin, water vapor/respiration

AV node

slows conduction through atria-ventricles, ensures maximum filling

pre load

stretch of ventricular fibers at end of diastole

total body fluid is influenced by

thirst (neuro control), water loss, age, gender, body fat

hypernatremia

thirst, flushed skin, fever asses. neuro changes, encourage fluids

3. A nurse is caring for a client who sustained significant blood loss. Which of the following is a manifestation of hypovolemia?

thready pulse

hyponatremia

thready pulse, tachy monitor for neuro changes and serum electrolytes

risk factors for impaired perfusion

smoking, elevated serum lipids, sedentary lifestyle, obesity, diabetes, hypertension

hyperphosphatemia

soft tissue, tetany avoid high phos. food

diffusion

solute move from area of higher concentration to one of lower

intracellular fluid

40 % of body weight

total body fluid

50-60% of body weigbt

risk factors of hypovolemia

GI, skin, poor kidney/adrenal function, 3rd spacing, hemorrhage, NPO

2. A nurse is caring for four hospitalized clients. Which of the following clients is at greatest risk for fluid volume deficit?

The client who has just been admitted with fever, vomiting, and diarrhea consistent with gastroenteritis.

Stroke Volume

Volume of blood ejected by L Ventricle each beat

cardiac output

amount of blood ejected by the left ventricle every minute

cellular functions depends on

amount/concentration/composition of body fluid

7. A nurse is teaching a client who takes loop diuretic and has a serum potassium level of 3.2 mEq/L. The nurse is providing dietary patient education. Which of the following foods should the nurse include in her instructions?

bananas

hypophosphatemia

confusion, muscle weakness, tissue hypoxia encourage foods high in phosphorus

hypercalcemia

constipation, fatigue, confusion, ECG changes, dysrhythmias protect from fractures, monitor digoxin

positioning for FVE

semi-fowlers

risk factors for fluid volume excess

heart failure, renal failure, cirrhosis of liver

fluid volume overload 2 main types

hypervolemia, hemodilution

5. The nurse is caring for a client with a fluid volume deficit (FVD). The nurse understands that the following may be associated with FVD:

hypovolemia hemoconcentration

fluid volume deficit two main types

hypovolemia, hemoconcentration (dehydration)

10. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? Select all that apply

increased HR increased BP increased RR

after load

pressure the ventricle must overcome

right ventricle

pumps blood through pulmonary artery to lungs, low pressure thin walls

left atrium

receives deoxygenated blood from lungs via pulmonary veins

functions of electrolytes

regulate fluid balance, regulate hormones, strengthen skeletal structures, catalyst nerve conduction, metabolism of nutrients, cardiac function