NUR198 Exam 1 · Older Adult · Fluid & Electrolytes

⭐ the Focused Review — High-Yield Snapshot

The must-know rules from your instructor’s Exam 1 review. 🚨 = emergency / absolute rule · ⭐ = high-yield. Full details in the modules below.

🚨 NEVER IV push potassium

Causes cardiac arrest. Always DILUTE (min 100 mL), max 10–20 mEq/hr peripheral, telemetry on, urine output ≥30 mL/hr before giving.

🚨 Hyperkalemia treatment ORDER

Calcium gluconate FIRST (protects the heart) → insulin + glucose → Kayexalate → loop diuretics → dialysis. ECG: peaked T waves → wide QRS.

🚨 Malignant hyperthermia

Sudden ↑↑temp (>104°F) + muscle rigidity + tachycardia during/after anesthesia → Dantrolene rapid IV (reconstitute with STERILE WATER only), stop triggers, active cooling, 100% O₂. Triggers: succinylcholine + volatile agents. Earliest sign = ↑ end-tidal CO₂.

🚨 Anastomotic leak (post-bariatric)

Unexplained tachycardia (HR >100) is the EARLIEST sign — appears BEFORE fever or pain. On an exam, pick the tachycardia over expected low-grade fever / absent bowel sounds / 6-10 pain.

🚨 Evisceration

Bowel through the incision → NEVER reinsert; cover with STERILE SALINE-soaked gauze (not dry); Semi-Fowler's, knees flexed; NPO; call surgeon → OR.

⭐ Confusion in an older adult

NEVER 'just normal aging.' Suspect infection (UTI!), fluid deficit, hypoxia, or meds FIRST. New-onset confusion can be the first cue of a fluid deficit.

⭐ Daily weight = best fluid indicator

1 kg ≈ 1 L of fluid. Same scale, same time, same clothing. Urine <30 mL/hr = report it.

⭐ ABGs — ROME

Respiratory Opposite (pH↑CO₂↓ / pH↓CO₂↑) · Metabolic Equal (pH↑HCO₃↑ / pH↓HCO₃↓). 1 value off + pH off = uncompensated; both off + pH normal = full compensation.

⭐ IV fluid tonicity

Iso (0.9%NS, LR) stays in vessels — dehydration/blood loss. Hypo (0.45%NS) cells swell — NEVER in ↑ICP. Hyper (3%NS) cells shrink — give slowly, watch pulmonary edema. D5W: isotonic in bag, hypotonic in body.

⭐ Post-op fever — 5 W's

Wind (atelectasis, 24–48h) · Water (UTI, 48–72h) · Wound (SSI, day 3–5) · Walk (DVT/PE, day 5+) · Wonder drugs (drug/transfusion rxn, any time).

⭐ PACU — airway is ALWAYS first

Airway → breathing → circulation. Aldrete score ≥7–10 = ready for discharge; it does NOT assess pain, nausea, urine output, or wound.

⭐ Post-op urine <30 mL/hr

Bladder scan FIRST. Full = retention (anesthesia paralyzed the detrusor) → straight cath. Empty = renal cause → assess further. Never cath before confirming.

⭐ Moderate (conscious) sedation

Client sedated but arousable, keeps own airway. Reversal at bedside: naloxone (opioids), flumazenil (benzos). Continuous pulse ox + capnography. Teach BEFORE (PACU is too drowsy).

⭐ Shingles (herpes zoster)

Reactivated VZV — unilateral, dermatomal rash that does NOT cross midline. Antivirals best <72h. Isolation: standard+contact if localized; airborne+contact if disseminated/immunocompromised. Don't assign a pregnant/non-immune nurse.

⭐ Melanoma — ABCDE

Asymmetry · Border irregular · Color varied · Diameter >6mm · Evolving. ANY one → refer for biopsy. Melanoma = deadliest; nurse teaches sun protection + self-exam, not 'watch and wait.'

⭐ Pain — self-report is gold standard

'Pain is whatever the patient says it is.' Match the scale: Numeric (alert adults), FACES (kids/language), FLACC (nonverbal), PAINAD (advanced dementia), CPOT (intubated). PCA: only the patient presses; older adults 'start low, go slow.'

Module 1 · Older Adult, Chronic Illness & Disability Exam 1

Expected Physiological Changes of Aging ★ High-yield

Normal aging — by system

Cardio: stiffer vessels → ↑systolic BP, slower HR response to stress, orthostatic hypotension (fall risk — rise slowly)
Resp: ↓lung elasticity, weaker cough, ↓cilia → pneumonia & aspiration risk
Renal: ↓GFR (drugs clear slower!), nocturia, ↓thirst sensation → dehydration risk
GI: ↓motility (constipation), ↓saliva, ↓intrinsic factor → B12 deficiency
Neuro: slower processing is normal — confusion is NEVER normal aging (work it up: infection? meds? hypoxia?)
Skin/MSK: thin fragile skin, ↓subcut fat, ↓bone density, ↓muscle mass → falls, fractures, pressure injuries, hypothermia
Senses: presbyopia, presbycusis (hear low tones better — speak low and slow, face the client), ↓taste/smell

Nursing management

Fall prevention bundle: assess risk, clutter-free, adequate lighting, nonslip footwear, call light in reach
Skin: reposition q2h, minimal tape, moisturize; med doses often lower ("start low, go slow")

⭐ New-onset confusion in an older adult = suspect UTI, infection, hypoxia, or medication effect FIRST — not "just aging" and not dementia.

Delirium vs Dementia ★ High-yield

	Delirium	Dementia
Onset	Sudden (hours–days)	Gradual (months–years)
Course	Fluctuates through the day; worse at night	Slowly progressive; stable day to day
Attention	Impaired — hallmark	Intact early
Cause	Reversible: infection (UTI!), meds, dehydration, hypoxia, surgery/anesthesia	Irreversible brain changes (Alzheimer most common)
Treatment	Find and fix the cause	Support function, safety, routines

Nursing care (both)

Reorient calmly, consistent caregivers, clocks/calendars, glasses/hearing aids ON, day-night routine, family at bedside
Avoid restraints and unnecessary sedatives (worsen both); safety = wandering precautions for dementia

Polypharmacy, Abuse & Ageism

Polypharmacy

Multiple meds + multiple prescribers + ↓renal/hepatic clearance = adverse events; anticholinergics, sedatives, opioids = Beers-list caution (falls, confusion)
Nursing: full med reconciliation every visit — include OTC + herbals; watch for a "prescribing cascade" (new drug to treat another drug's side effect)

Elder abuse

Types: physical, emotional, sexual, financial, neglect (most common); abuser is usually a known caregiver
Red flags: injuries inconsistent with story, delays seeking care, poor hygiene/dehydration, caregiver answers all questions, fear of caregiver
Nurses are mandatory reporters — interview the client alone; report suspicion (you don't have to prove it)

Ageism

Stereotyping by age → undertreated pain, dismissed symptoms. Assess the person, not the birth year.

Chronic Illness & Disability Management

Chronic = lasts ≥3 months (usually lifelong), fluctuates through remissions/exacerbations; goal = manage, not cure — maximize function and quality of life
Trajectory phases: onset → stable → unstable → acute flare → comeback → downward → dying; nursing focus shifts by phase
Self-management support = the core: teach-back method, simplify regimens, address cost/access barriers, involve family/caregivers
Watch caregiver strain; connect to community resources; depression and social isolation are common — screen for both

Module 2 · Fluid, Electrolyte & Acid–Base Balance Exam 1

More Fluid & Electrolyte graphics 1 graphics

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All Electrolytes Cheat Sheet

Fluid Volume: Hypovolemia vs Hypervolemia ★ High-yield

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Fluid Balance & Fluid Overload

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Signs & Symptoms FVO vs. FVD

	Hypovolemia (deficit)	Hypervolemia (overload)
Causes	Vomiting, diarrhea, hemorrhage, diuretics, burns, poor intake	Heart failure, renal failure, excess IV fluids/Na⁺, cirrhosis
S/S	↑HR, ↓BP, orthostatic, ↑ urine specific gravity, dry mucosa, ↓skin turgor, ↓UOP, weight loss	Bounding pulse, ↑BP, JVD, crackles, edema, dyspnea, weight gain
Priority	Isotonic fluids (NS/LR), safety (falls), monitor UOP	Restrict Na⁺/fluid, diuretics, daily weight, semi-Fowler, O₂

⭐ Daily weight is the best indicator of fluid status — 1 kg = ~1 L. Same scale, same time, same clothing.

Potassium (3.5–5.0) — Hypo vs Hyper ★ High-yield

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Potassium (K⁺) – NCLEX High-Yield

Potassium, Sodium, Chloride

Serum Potassium (K⁺) – Range & Guide

Sodium–Potassium Pump (NOKIA mnemonic)

	Hypokalemia <3.5	Hyperkalemia >5.0
Causes	Diuretics, vomiting/diarrhea, NG suction, insulin	Renal failure, K⁺-sparing diuretics, ACE inhibitors, tissue damage, acidosis
S/S	Muscle weakness/cramps, ↓reflexes, flat T waves, U waves, ileus, arrhythmias	Muscle weakness, peaked T waves, wide QRS, bradycardia → arrest
Nursing	Replace K⁺ (NEVER IV push — always diluted/pump, max ~10 mEq/hr; give oral with food); cardiac monitor	Restrict K⁺; kayexalate; IV calcium gluconate (protects heart); insulin+D50, albuterol shift K⁺ in; dialysis

🚨 IV potassium is NEVER pushed — always diluted and on a pump. Assess urine output before giving (no pee, no K⁺).

Sodium (135–145) — Hypo vs Hyper

Hyponatremia <135: neuro (confusion, seizures, headache) from cell swelling. Causes: SIADH, excess water, diuretics. Tx: fluid restriction; hypertonic (3%) saline only for severe — correct SLOWLY (rapid = osmotic demyelination)
Hypernatremia >145: thirst, dry mucosa, restless→lethargy, seizures. Causes: dehydration, ↓water intake, DI. Tx: hypotonic fluids/water, correct slowly (rapid = cerebral edema)

⭐ Sodium = the neuro electrolyte. "Where sodium goes, water follows."

Calcium (9–10.5) & Magnesium (1.3–2.1)

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Hypocalcemia: ↑neuromuscular excitability — +Trousseau (BP cuff→hand spasm), +Chvostek (cheek tap→twitch), tetany, laryngospasm, seizures. Causes: thyroid/parathyroid surgery, renal failure. Tx: IV calcium gluconate
Hypercalcemia: "moans, groans, stones, bones" — weakness, ↓reflexes, kidney stones, constipation. Causes: hyperparathyroid, cancer, immobility. Tx: hydrate, ambulate, bisphosphonates
Calcium and phosphorus are inverse; calcium and magnesium act the same direction clinically
Hypomagnesemia: like hypocalcemia (tremor, +Chvostek/Trousseau, torsades). Hypermagnesemia: ↓reflexes, ↓BP, resp depression (classic in preeclampsia Mg therapy → antidote calcium gluconate)

Acid–Base / ABG Interpretation ★ High-yield

Normals

pH 7.35–7.45 · PaCO₂ 35–45 (respiratory) · HCO₃ 22–26 (metabolic)

ROME shortcut

Respiratory Opposite: pH & CO₂ move opposite ways
Metabolic Equal: pH & HCO₃ move the same way

Disorder	pH	Cause examples
Resp acidosis	↓ (↑CO₂)	Hypoventilation, COPD, opioid overdose, OSA
Resp alkalosis	↑ (↓CO₂)	Hyperventilation, anxiety, pain, early sepsis
Metabolic acidosis	↓ (↓HCO₃)	DKA, renal failure, diarrhea, lactic acidosis
Metabolic alkalosis	↑ (↑HCO₃)	Vomiting, NG suction, antacids, diuretics

⭐ Steps: 1) pH acid or alkaline? 2) which value matches the pH direction? (CO₂=resp, HCO₃=metabolic) 3) is the other value compensating?

IV Fluid Therapy + I&O / Rate Math Procedure

Isotonic (NS 0.9%, LR): stays in vessels → fluid resuscitation, blood loss (LR not with blood; NS is)
Hypotonic (0.45% NS): shifts INTO cells → cellular dehydration/hypernatremia (watch cerebral edema)
Hypertonic (3% NS, D10): pulls fluid OUT of cells → severe hyponatremia, cerebral edema; ICU, slow, monitor closely

The two calculations they test

IV rate (mL/hr) = total volume ÷ hours. Drip (gtt/min) = (volume × drop factor) ÷ minutes.
I&O: count all fluids in (PO, IV, tube) and out (urine, emesis, drains, liquid stool). 1 oz = 30 mL; goal urine ≥ 30 mL/hr.

⭐ Full worked examples are in the ✅ Practice Qs tab (dosage section).

Module 3 · Perioperative, Pain & Integument Exam 1

Perioperative Nursing ★ High-yield

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Ambulation (Body Mechanics & Mobility)

Asepsis & Handwashing

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PPE & Infection Control

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Surgical Prefixes & Suffixes

Pre-op

Informed consent: provider explains risks/benefits; nurse witnesses the signature & confirms understanding. Must be signed BEFORE sedation.
NPO (usually after midnight/8 hr), hold/adjust meds (anticoagulants, insulin, some herbals), baseline vitals/labs, remove jewelry/dentures, teach coughing/IS/leg exercises, mark site, verify allergies

Intra-op

Time-out (right patient/site/procedure), sterile field, positioning injury & skin protection, counts (sponges/instruments)

Post-op priorities (PACU → floor)

Airway → breathing → circulation first. Then LOC, pain, surgical site/drains, N/V
Prevent complications: IS + early ambulation (atelectasis/pneumonia, VTE), splint incision, monitor for hemorrhage (↑HR early), infection, paralytic ileus (bowel sounds/flatus)
Dehiscence/evisceration: cover with sterile saline-soaked gauze, low-Fowler with knees bent, NPO, stay calm, call surgeon

Malignant Hyperthermia & Anesthesia Emergency

Rare genetic reaction to inhaled anesthetics + succinylcholine → uncontrolled muscle hypermetabolism
Earliest sign = ↑ end-tidal CO₂; earliest reliable clinical = masseter (jaw) rigidity, tachycardia. Hyperthermia is a LATE sign.
Antidote = dantrolene; stop the agent, 100% O₂, cool the client, treat hyperkalemia/arrhythmias
Anesthesia types: general (airway priority), regional/spinal (watch hypotension, high block → resp compromise), local, moderate sedation

Obesity & Bariatric Surgery

Qualify: BMI ≥40, or ≥35 with comorbidities, after failed conservative attempts
Post-op: small sips → tiny frequent meals, protein first, no gulping, no straws/carbonation; risk of anastomotic leak (tachycardia, fever, ↑ pain → report), VTE, dumping syndrome
Lifelong vitamin/mineral supplementation (B12, iron, Ca, D); airway/OSA precautions; bariatric-appropriate equipment + dignity

Pain Management ★ High-yield

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Pain is what the client says it is — self-report is the gold standard. Use FLACC (nonverbal/kids), Wong-Baker faces, 0–10 numeric; PAINAD for dementia
WHO ladder: non-opioids (acetaminophen — watch 4 g/day max, NSAIDs — GI/renal/bleeding) → weak → strong opioids; multimodal is best
Opioids: monitor sedation + RR FIRST (respiratory depression is the danger); naloxone reverses; prevent constipation proactively (stimulant laxative, not just fiber)
Non-pharm: heat/cold, positioning, distraction, massage, relaxation, TENS — adjuncts, not replacements

Integument: Dermatitis, Zoster, Psoriasis, Skin Cancer

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Atopic dermatitis (eczema): dry itchy inflamed skin; moisturize, avoid triggers, topical steroids, don't scratch
Herpes zoster (shingles): reactivated varicella along a dermatome (unilateral, doesn't cross midline), painful vesicles. Airborne + contact precautions if disseminated/immunocompromised; antivirals within 72 hr; risk of postherpetic neuralgia. Contagious to non-immune until crusted.
Psoriasis: silvery scaly plaques (autoimmune, ↑ cell turnover); topical steroids, vitamin D analogs, phototherapy, biologics; not contagious
Skin cancers — ABCDE for melanoma: Asymmetry, Border irregular, Color varied, Diameter >6 mm, Evolving. AK = precancerous; BCC = most common, rarely metastasizes; SCC can metastasize; melanoma = deadliest. Teach sun protection + monthly skin checks
Skin grafts/flaps: monitor color/temp/cap refill of graft, immobilize, prevent pressure/shear on site