NR324 EXAM 1/NR-324 ADULT HEALTH 1 EXAM 1 LATEST 2 VERSIONS A AND
B 2023-2024 ACTUAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS|AGRADE
- What are possible causes of hypervolemia? known as “fluid overload” and occurs when the body retains
more
water than it needs. - What are the clinical manifestations of hypervolemia? Crackles, edema, Increased pulses, Jugular vein
distention,
weight gain - What are remarks that a patient might say if they are experiencing fluid volume overload?
- What are the vital signs changes you’ll see with hypervolemia? Increased or slowed HR, increased blood
pressure, Edema - What are specific nursing assessments to assess for hypervolemia? Mental status, crackles, SOB, Cough,
frothy
sputum - What is the treatment for these patients? Reduce fluid intake, reduce sodium intake,
o What are the different types of diuretics? Loop diuretics, thiazide diuretics, potassiumsparing
diuretics
o How would you educate your patient with each type? Thiazide – Instruct patient to
monitor weight weekly and report significant changes. Use sunscreen to prevent
photosensitivity reactions. Advise patient to consult health care professional before
taking OTC medication concurrently with this therapy. Instruct patient to notify health
care professional of medicationregimen before treatment or surgery, Advise patient to
contact health care professional immediately if muscle weakness, cramps, nausea,
dizziness, or numbness or tingling of
extremities occurs. - What are possible causes of hypovolemia? Diarrhea and vomiting are common causes of body fluid loss.
Fluid
can also be lost as a result of large burns, excessive perspiration, or diuretics. - What are the clinical manifestations of hypovolemia? Headache, fatigue, dizziness, nausea, cold clammy
skin,
rapid heartbeat, rapid sallow breathing, weak pulse, confusion, little or no output - What are remarks that a patient might say if they are experiencing dehydration?
- What are the vital signs changes you’ll see with hypervolemia? High temperature, increased heart rate,
decreased blood pressure, and faster breathing , - What are specific nursing assessments to assess for hypovolemia? including thirst, weight loss, dry
mucousmembranes, sunken-appearing eyes, decreased skin turgor, increased capillary refill time,
hypotension and
postural hypotension, tachycardia, weak and thready peripheral pulses, flat neck veins - What is the treatment for these patients? Replacement of fluids
- What are way’s to measure fluid volume status? In and outs
- Which measurement is the best way to measure total body fluid gains/loss? Daily weight
- What are lab value ranges, action in the body, clinical manifestation and treatments of the following:
Sodium 135-145 mEq/L
seizuresPotassium 3.5-
5mEq/L Magnesium 1.5-2.5
mEq/L Phosphorus 2.4-
4.4mg/dL Calcium 8.6-10.2
mEq/L
3
3
3
- Know how to interpret ABG results and evaluate priority ABG’s (aka terrible ABGs, which ABG result
you would
assess first)
PH:7.35-
7.45
CO2:45-35
HCO3:22-
26
Partial comp- all three values> OUT OF RANGE
Fully comp- pH is NORMAL; CO2 & HCO3 are OUT
OF RANGEUncomp- pH & CO2 are OUT OF
RANGE; HCO3 are NORMAL - Evaluate pH
- Analyze PaCO2
- Analyze HCO3–
- Determine if CO2 or HCO3– matches the alteration
- Decide if the body is attempting to compensate
- What type of clinical manifestations and treatments would you expect with each:
o Metabolic acidosis-Carbonic acid deficit caused by Hypoxemia from acute pulmonary
disordersHyperventilation.
- Increased CO2 excretion by lungs
- Kussmaul respirations (deep and rapid)
- Kidneys excrete acid
o Metabolic alkalosis-Base bicarbonate excess caused by Prolonged vomiting or gastric suction - Gain of HCO –
▪ Compensatory mechanisms - Renal excretion of HCO –
- Decreased respiratory rate to increase plasma CO2 (limited)
o Respiratory acidosis- Carbonic acid excess caused by - Hypoventilation
- Respiratory failure
▪ Compensation - Kidneys conserve HCO –
and secrete H
+
into urine
o Respiratory alkalosis- Carbonic acid deficit caused by Hypoxemia from acute pulmonary disorders
▪ Hyperventilation
- Describe each of the IV fluids (ECF/ICF changes), names of IV fluids in each category (ex. LR, 0.9
NS, 0.45 NS,etc.), when they are used and nursing assessment associated with each:
o Hypotonic- H2O into cells swell.
▪ Solutions:
- D5W
- 0.45% NaCL
o normal daily losses
▪ due to potential cellular swelling, monitor patients for changes in mentation that may
indicatecerebral edema.
o Hypertonic- H2O out of cell shrinks