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