Victims of the hurricane are currently living in the evacuation center for those who lost their homes during the tempest. The drinking water is taken from a nearby faucet but it is not tested for potability. After a few days of drinking from the faucet, many evacuees, mostly children, experienced severe diarrhea and vomiting. Later on, muscle weakness is becoming evident, and abdominal distention are noted. most of the evacuees were diagnosed with hypokalemia.
- 1 Description
- 2 Homeostasis
- 3 Body Fluids
- 4 Fluid and Electrolyte Transport
- 5 Fluid and Electrolyte Balance
- 6 Acid-Base Balance
- 7 Classification
- 8 Pathophysiology
- 9 Causes
- 10 Clinical Manifestations
- 11 Complications
- 12 Assessment and Diagnostic Findings
- 13 Medical Management
- 14 Nursing Management
- 15 Practice Quiz: Fluids and Electrolytes
- 16 See Also
- 17 Further Reading
Fluid and electrolyte balance is a dynamic process that is crucial for life and homeostasis.
- Fluid occupies almost 60% of the weight of an adult.
- Body fluid is located in two fluid compartments: the intracellular space and the extracellular space.
- Electrolytes in body fluids are active chemicals or cations that carry positive charges and anions that carry negative charges.
- The major cations in the body fluid are sodium, potassium, calcium, magnesium, and hydrogen ions.
- The major anions are chloride, bicarbonate, sulfate, and proteinate ions.
Homeostasis is the dynamic process in which the body maintains balance by constantly adjusting to internal and external stimuli.
Negative and Positive Feedback
- Feedback is the relaying of information about a given condition to the appropriate organ or system.
- Negative feedback. Negative feedback occurs when the body reverses an original stimulus for the body to regain physiologic balance.
- Positive feedback. Positive feedback enhances or intensifies the original stimulus.
- Examples. Blood pressure control and maintenance of normal body temperature are examples of negative feedback while blood clotting after an injury and a woman in labor are examples of positive feedback.
Systems Involved in Feedback
The major systems involved in feedback are the nervous and endocrine systems.
- Nervous system. The nervous system regulates homeostasis by sensing system deviations and sending nerve impulses to appropriate organs.
- Endocrine system. The endocrine system uses the release and action of hormones to maintain homeostasis.
Fluids make up a large portion of the body, which is approximately 50%-60% of the total body weight.
Location of Fluids
- Main compartments. Body fluids are divided between two main compartments: the intracellular fluid and the extracellular fluid compartments.
- Intracellular fluid. Intracellular fluid functions as a stabilizing agent for the parts of the cell, helps maintain cell shape, and assists with transport of nutrients across the cell membrane, in and out of the cell.
- Extracellular fluid. Extracellular fluid mostly appears as interstitial tissue fluid and intravascular fluid.
Fluid Regulation Mechanisms
- The thirst center. The thirst center in the hypothalamus stimulates or inhibits the desire for a person to drink.
- Antidiuretic hormone. ADH regulates the amount of water the kidney tubules absorb and is released in response to low blood volume or in response to an increase in concentration of sodium and other solutes in the intravascular fluids.
- The RAA system. The RAA system controls fluid volume, in which when the blood volume decreases, blood flow to the renal juxtaglomerular apparatus is reduced, thereby activating the RAA system.
- Atrial natriuretic peptide. The heart also plays a role in correcting overload imbalances, by releasing ANP from the right atrium.
Normal Intake and Output
- Daily intake. An adult human at rest takes appropriately 2,500 ml of fluid daily.
- Levels of intake. Approximate levels of intake include fluids 1, 200 ml, foods 1, 000 ml, and metabolic products 30 ml.
- Daily output. Daily output should approximately equal in intake.
- Normal output. Normal output occurs as urine, breathing, perspiration, feces, and in minimal amounts of vaginal secretions.
Overhydration and Edema
- Overhydration. Overhydration is an excess of water in the body.
- Edema. Edema is the excess accumulation of fluid in interstitial tissue spaces, also called third-space fluid.
- Cause of edema. Edema is caused by a disruption of the filtration and osmotic forces of the body’s circulating fluids.
- Treatment of edema. Diuretics are commonly given for systemic edema.
- Dehydration. Dehydration is a deficiency of body water or excessive loss of water.
- External causes. External causes of dehydration include prolonged sun exposure and excessive exercise, as well as diarrhea, vomiting, and burns.
- Treatment of dehydration. Supplemental fluids and electrolytes are often administered.
An electrolyte is a substance that will disassociate into ions when dissolved in water.
- Origins. Electrolytes are found in the form of inorganic salts, acids, and bases.
- Active chemicals. Electrolyte concentrations are measured according to their chemical activity and expressed as milliequivalents.
- Ions. Each chemical element has an electrical charge, either positive or negative.
- Intracellular electrolytes. Important intracellular electrolytes are potassium, magnesium, sulfate, and phosphate, and the most dominant cation iss potassium while the most dominant anion is phosphate.
- Extracellular electrolytes. Important extracellular electrolytes include sodium, chlorine, calcium, and bicarbonate, and the most essential cation is sodium while chlorine is the most important anion.
Fluid and Electrolyte Transport
Total electrolyte concentration affects the body’s fluid balance.
- The body cells. Nutrients and oxygen should enter body cells while waste products should exit the body.
- The cell membrane. The cell membrane separates the intracellular environment from the extracellular environment.
- Permeability. The ability of a membrane to allow molecules to pass through is known as permeability.
Permeability of Membranes
- Freely permeable membranes. These membranes allow almost any food or waste substance to pass through.
- Selectively permeable. The cell membrane is selectively permeable, meaning that each cell’s membrane allows only certain specific substances to pass through.
- Passive transport. Passive transport mechanisms include diffusion, osmosis, and filtration.
- Diffusion. Diffusion, or the process of “being widely spread”, is the random movement of molecules from an area of higher concentration to an area of lower concentration.
- Osmosis. Osmosis is the diffusion of a pure solvent, such as water, across a semipermeable membrane in response to a concentration gradient in situations where the molecules of a higher concentration are non diffusible.
- Filtration. Filtration is the transport of water and dissolved materials concentration already exists in the cell.
- Mechanisms. Active transport mechanisms require specific enzymes and an energy expenditure in the form of adenosine triphosphate (ATP).
- Processes. Active transport processes can move solutes “uphill”, against the normal rules of concentration and pressure.
Fluid and Electrolyte Balance
Fluid and electrolyte balance is vital for proper functioning of all body systems.
- Osmolarity. This is the property of particles in a solution to dissociate into ions.
- Electroneutrality. This is the balance of positive and negative charges.
Acid-base balance is another important aspect of homeostasis.
Acid, Bases, and Salts
- Acid. An acid is one type of compound that contains the hydrogen ion.
- Base. A base or alkali is a compound that contains the hydroxyl ion.
- Salt. A salt is a combination of a base and an acid and is created when the positive ions of a base replace the positive hydrogen ions of an acid.
- Important salts. The body contains several important salts like sodium chloride, potassium chloride, calcium chloride, calcium carbonate, calcium phosphate, and sodium phosphate.
Potential of Hydrogen
- pH. The symbol of pH refers to the potential or power of hydrogen ion concentration within the solution.
- Low pH. If the pH number is lower than 7, the solution is an acid.
- High pH. If the pH is greater than 7, a solution is basic or alkaline.
- Neutral pH. If the pH is 7, then the solution is neutral.
- Changes. A change in the pH of a solution by one pH unit means a tenfold change in hydrogen concentration.
- Buffers. A buffer is a chemical system set up to resist changes, particularly in hydrogen ion levels.
- Bicarbonate buffer system. Sodium bicarbonate and carbonic acid are the body’s major chemical buffers.
- Carbon dioxide. The major compound controlled by the lungs is CO2, and the respiratory system can very rapidly compensate for too much acid and too little acid by increasing or decreasing the respiratory rate, thereby altering the level of CO2.
- Bicarbonate. Bicarbonate ions are basic components in the body, and the kidneys are key in regulating the amount of bicarbonate in the body.
- Measurement of arterial blood gas. The pH level and amounts of specific gases in the blood indicate if there is more acid or base and their associated values.
- Respiratory acidosis. Respiratory acidosis occurs when breathing is inadequate and PaCO2 builds up.
- Respiratory alkalosis. Respiratory alkalosis occurs as a result of hyperventilation or excess aspirin intake.
- Metabolic acidosis. In metabolic acidosis, metabolism is impaired, causing a decrease in bicarbonates and a buildup of lactic acid.
- Metabolic alkalosis. Metabolic alkalosis occurs when bicarbonate ion concentration increases, causing an elevation in blood pH.
There are different fluid volume disturbances that may affect an individual.
- Fluid volume deficit or hypovolemia occurs when loss of ECF volume exceeds the intake of fluid.
- Fluid volume excess or hypervolemia refers to an isotonic volume expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF.
Disturbances in electrolyte balances are common in clinical practice and must be corrected.
- Hyponatremia refers to a serum sodium level that is less than 135 mEq/L
- Hypernatremia is a serum sodium level higher than 145 mEq/L.
- Hypokalemia usually indicates a deficit in total potassium stores.
- Hyperkalemia refers to a potassium level greater than 5.0 mEq/L.
- Hypocalcemia are serum levels below 8.6 mg/dl.
- Hypercalcemia is calcium level greater than 10.2 mg/dl.
- Hypomagnesemia refers to a below-normal serum magnesium concentration.
- Hypermagnesemia are serum levels over 2.3 mg/dl.
- Hypophosphatemia is indicated by a value below 2.5 mg/dl.
- Hyperphosphatemia is a serum phosphorus level that exceeds 4.5 mg/dl in adults.
Nurses need an understanding of the pathophysiology of fluid and electrolyte balance to anticipate, identify, and respond to possible imbalances.
- Concentrations. Electrolyte concentrations vary from those in the ICF to those in the ECF.
- Sodium. Sodium ions outnumber any other cations in the ECF; therefore it is essential in the fluid regulation of the body.
- Potassium. The ECF has a low concentration of potassium and can tolerate only small changes in its concentrations.
- Maintenance. The body expends a great deal of energy in maintaining the sodium and potassium concentrations through cell membrane pumps that exchange sodium and potassium ions.
- Osmosis. When two different solutions are separated by a membrane that is impermeable to the dissolved substances, fluid shifts from the region of low solute concentration to the high solute concentration until the solutions are of equal concentrations.
- Diffusion. Diffusion is the natural tendency of a substance to move in an area of higher concentration to an area of lower concentration.
Causes of fluid and electrolyte imbalances are discussed below in general.
- Fluid retention. Retention of sodium is associated with fluid retention.
- Loss of sodium. Excessive loss of sodium is associated with decreased volume of body fluid.
- Trauma. Trauma causes release of intracellular potassium which is extremely dangerous.
- Loss of body fluids. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake.
- Fluid overload. Fluid volume excess may be related to a simple fluid overload or diminished function of the homeostatic mechanisms responsible for regulating fluid balance.
- Low or high electrolyte intake. Diets low or excessive in electrolytes could also cause electrolyte imbalances.
- Medications. There are certain medications that could lead to electrolyte imbalances when taken against the physician’s orders.
Signs and symptoms that occur in fluid and electrolyte imbalances are discussed below.
- Fluid volume deficit. Clinical signs and symptoms include acute weight loss, decreased skin turgor, oliguria, concentrated urine, orthostatic hypotension, a weak, rapid heart rate, flattened neck veins, increased temperature, thirst, decreased or delayed capillary refill, cool, clammy skin, muscle weakness, and cramps.
- Fluid volume excess. Clinical manifestations for FVE include edema, distended neck veins, and crackles.
- Hyponatremia. Signs and symptoms include anorexia, nausea and vomiting, headache, lethargy, dizziness, confusion, muscle cramps and weakness, muscular twitching, seizures, dry skin, and edema.
- Hypernatremia. The signs and symptoms are thirst, elevated body temperature, hallucinations, lethargy, restlessness, pulmonary edema, twitching, increased BP and pulse.
- Hypokalemia. Clinical manifestations are fatigue, anorexia, muscle weakness, polyuria, decreased bowel motility, paresthesia, ileus, abdominal distention, and hypoactive reflexes
- Hyperkalemia. Signs and symptoms include muscle weakness, tachycardia, paresthesia, dysrhythmias, intestinal colic, cramps, abdominal distention, and anxiety.
- Hypocalcemia. The signs and symptoms are numbness, tingling of fingers, toes, and circumoral region, positive Trousseau’s sign and Chvostek’s sign, seizures, hyperactive deep tendon reflexes, irritability, and bronchospasm.
- Hypercalcemia. The signs and symptoms include muscle weakness, constipation, anorexia, nausea and vomiting, dehydration, hypoactive deep tendon reflexes lethargy, calcium stones, flank pain, pathologic fractures, and deep bone pain.
- Hypomagnesemia. Clinical manifestations include neuromuscular irritability, positive Trousseau’s and Chvostek’s sign, insomnia, mood changes, anorexia, vomiting, and increased deep tendon reflexes.
- Hypermagnesemia. Signs and symptoms are flushing, hypotension, muscle weakness, drowsiness, hypoactive reflexes, depressed respirations, and diaphoresis.
- Hypophosphatemia. Signs and symptoms include paresthesias, muscle weakness, bone pain and tenderness, chest pain, confusion, seizures, tissue hypoxia, and nystagmus.
- Hyperphosphatemia. Clinical manifestations are tetany, tachycardia, anorexia, nausea and vomiting, muscle weakness, and hyperactive reflexes.
Fluid and electrolyte imbalances could result in complications if not treated promptly.
- Dehydration. Fluid volume deficit could result in dehydration of the body tissues.
- Cardiac overload. Fluid volume excess could result in cardiac overload if left untreated.
- SIADH. Water is retained abnormally in SIADH.
- Cardiac arrest. Too much potassium administered could lead to cardiac arrest.
Assessment and Diagnostic Findings
The following are laboratory studies useful in diagnosing fluid and electrolyte imbalances:
- BUN. BUN may be decreased in FVE due to plasma dilution.
- Hematocrit. Hematocrit levels in FVD are greater than normal because there is a decreased plasma volume.
- Physical examination. Physical exam is necessary to observe the signs and symptoms of the imbalances.
- Serum electrolyte levels. Measurement of electrolyte levels should be performed to check for presence of an imbalance.
- ECG. ECG changes can also contribute to the diagnosis of fluid and electrolyte imbalance.
- ABG analysis. ABG analysis may reveal acid-base imbalances.
Treatment of fluid and volume imbalances needs accuracy to avoid consequences that can result in complications.
- Isotonic electrolyte solutions. These solutions are used to treat the hypotensive patient with FVD because they expand plasma volume.
- Accurate I&O. Accurate and frequent assessments of I&O should be performed when therapy should be slowed or increased to prevent volume deficit or overload.
- Dialysis. Hemodialysis or peritoneal dialysis is performed to remove nitrogenous wastes and control potassium and acid-base balance, and to remove sodium and fluid.
- Nutritional therapy. Treatment of fluid and electrolyte imbalances should involve restrictions or enforcement of the concerned electrolyte.
- AVP receptor agonists. These are new pharmacologic agents that treat hyponatremia by stimulating free water excretion.
- Diuretics. To decrease fluid volume in FVE, diuretics are administered.
- IV calcium gluconate. If serum potassium levels are dangerously elevated, it may be necessary to administer IV calcium gluconate.
- Calcitonin. Calcitonin can be used to lower the serum calcium level and is particularly useful for patients with heart disease or heart failure who cannot tolerate large sodium loads.
Nurses may use effective teaching and communication skills to help prevent and treat various fluid and electrolyte disturbances.
Close monitoring should be done for patients with fluid and electrolyte imbalances.
- I&O. the nurse should monitor for fluid I&O at least every 8 hours, or even hourly.
- Daily weight. Assess the patient’s weight daily to measure any gains or losses.
- Vital signs. Vital signs should be closely monitored.
- Physical exam. Physical exam is needed to reinforce other data about a fluid or electrolyte imbalance.
The following diagnoses are found in patients with fluid and electrolyte imbalances.
- Excess fluid volume related to excess fluid intake and sodium intake.
- Deficient fluid volume related to active fluid loss or failure of regulatory mechanisms.
- Imbalanced nutrition: less than body requirements related to inability to ingest food or absorb nutrients.
- Imbalanced nutrition: more than body requirements related to excessive intake.
- Diarrhea related to adverse effects of medications or malabsorption.
Nursing Care Planning & Goals
Planning and goals for fluid and electrolyte imbalances include:
- Maintenance of fluid volume at a functional level.
- Display of normal laboratory values.
- Demonstration appropriate changes in lifestyle and behaviors including eating patterns and food quantity/quality.
- Reestablishment and maintenance of normal pattern and GI functioning.
There are specific nursing interventions for fluid and electrolyte imbalances that can aid in alleviating the patient’s condition.
- Monitor turgor. Skin and tongue turgor are indicators of the fluid status of the patient.
- Urine concentration. Obtain urine sample of the patient to check for urine concentration.
- Oral and parenteral fluids. Administer oral or parenteral fluids as indicated to correct the deficit.
- Oral rehydration solutions. These solutions provide fluid, glucose, and electrolytes in concentrations that are easily absorbed.
- Central nervous system changes. The nurse must be alert for central nervous system changes such as lethargy, seizures, confusion, and muscle twitching.
- Diet. The nurse must encourage intake of electrolytes that are deficient or restrict intake if the electrolyte levels are excessive.
Evaluation of the care plan can check the effectiveness of the treatments. The interventions are deemed effective if the client has:
- Maintained fluid volume at a functional level.
- Displayed normal laboratory results.
- Demonstrated appropriate changes in lifestyle and behaviors including eating patterns and food quantity/quality.
- Reestablished and maintained normal pattern and GI functioning.
Discharge and Home Care Guidelines
After hospitalization, treatment and maintenance of the condition must continue at home.
- Diet. A diet rich in all the nutrients and electrolytes that a person needs should be enforced.
- Fluid intake. Fluid intake must take shape according to the recommendations of the physician.
- Follow-up. A week after discharge, the patient must return for a follow-up checkup for evaluation of electrolyte and fluid status.
- Medications. Compliance to prescribed medications should be strict to avoid recurrence of the condition.
Data should be documented for future medical and legal references. The nurse must document:
- Individual findings, including factors affecting ability to manage body fluids and degree of deficit.
- I&O, fluid balance, changes in weight, urine specific gravity, and vital signs.
- Results of diagnostic testing and laboratory studies.
- Plan of care.
- Client’s responses to treatment, teaching, and actions performed.
- Attainment or progress toward desired outcome.
- Modifications to plan of care.
Practice Quiz: Fluids and Electrolytes
Here’s a 10-item quiz about the study guide:
In Exam Mode: All questions are shown but the results, answers, and rationales (if any) will only be given after you’ve finished the quiz.
Practice Quiz: Fluids and Electrolytes
Practice Mode: This is an interactive version of the Text Mode. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. No time limit for this exam.
Practice Quiz: Fluids and Electrolytes
1. ECF is primarily composed of:
A. Aqueous fluid and lymphatic fluid.
B. CSF and interstitial fluid.
C. Interstitial and intravascular fluids.
D. Vascular fluid and CSF.
2. A chemical set up to resist changes, particularly in the level of pH, is:
A. A base.
B. A buffer.
C. A salt.
D. An acid.
3. Water moves across a semipermeable membrane via which process?
A. Active transport.
4. To balance water output, an average adult must have daily fluid intake of approximately:
A. 500-900 ml.
B. 1,000-2,000 ml.
C. 2,000-3,000 ml.
D. 4,000-6,000 ml.
5. The primary organs involved in pH regulation are:
A. Kidneys and lungs.
B. Heart and intestines.
C. Lung and endocrine glands.
D. Skin and kidneys.
6. A clinical manifestation not found in hypokalemia is:
A. Muscle weakness
C. Postural hypotension
7. The nurse should expect that a patient with mild fluid volume excess would be prescribed a diuretic that blocks sodium reabsorption in the distal tubule, such as:
8. Nursing intervention for a patient with a diagnosis of hyponatremia includes all of the following except:
A. Assessing for symptoms of nausea and malaise.
B. Encouraging the intake of low-sodium liquids such as coffee or tea.
C. Monitoring neurologic status
D. Restricting tap water intake.
9. To supplement a diet with foods rich in potassium, the nurse should recommend the addition of:
A. Fruits such as bananas and apricots
B. Green leafy vegetables
C. Milk and yogurt
D. Nuts and legumes
10. The most characteristic manifestation of hypocalcemia and hypomagnesemia is:
A. Anorexia and nausea.
C. Lack of coordination
Answers and Rationale
1. Answer: C. Interstitial and intravascular fluids.
- C: The extracellular fluid is primarily composed of interstitial and intravascular fluids.
- A: Aqueous fluid and lymphatic fluid is not a part of the ECF.
- B: CSF is not a part of ECF while interstitial fluid is.
- D: Vascular fluid and CSF is not a part of the ECF.
2. Answer: B. A buffer.
- B: A buffer is a chemical system set up to resist changes, particularly in hydrogen ion levels.
- A: A base or alkali is a compound that contains the hydroxyl ion.
- C: A salt is a combination of a base and an acid and is created when the positive ions of a base replace the positive hydrogen ions of an acid.
- D: An acid is one type of compound that contains the hydrogen ion.
3. Answer: D. Osmosis.
- D: Osmosis is the diffusion of a pure solvent, such as water, across a semipermeable membrane in response to a concentration gradient in situations where the molecules of a higher concentration are non diffusible.
- A: Active transport mechanisms require specific enzymes and energy expenditure in the form of adenosine triphosphate (ATP).
- B: Diffusion, or the process of “being widely spread”, is the random movement of molecules from an area of higher concentration to an area of lower concentration.
- C: Filtration is the transport of water and dissolved materials concentration already exists in the cell.
4. Answer: C. 2,000-3,000 ml.
- C: An adult human at rest takes appropriately 2, 500 ml of fluid daily.
- A: 500-900 ml is inadequate fluid intake.
- B: 1,000-2,000 ml is inadequate fluid intake.
- D: 4,000-6,000 ml is inadequate fluid intake.
5. Answer: A. Kidneys and lungs.
- A: The kidneys and lungs are the primary organs involved in pH regulation.
- B: The heart and the intestines are not involved in pH regulation.
- C: The lung and endocrine glands are not involved in pH regulation.
- D: The skin and kidneys are not involved in pH regulation.
6. Answer: B. Oliguria
- B: Polyuria is present in hypokalemia instead of oliguria.
- A: Muscle weakness is a clinical manifestation of hypokalemia.
- C: Postural hypotension a clinical manifestation of hypokalemia.
- D: Bradycardia a clinical manifestation of hypokalemia
7. Answer: D. Lasix
- D: Lasix is a diuretic commonly prescribed for patients with mild fluid volume excess.
- A: Bumex is not recommended for patients with mild fluid volume excess.
- B: Demadex is not recommended for patients with mild fluid volume excess.
- C: HydroDIURIL is not the diuretic that blocks sodium reabsorption in the distal tubule.
8. Answer: B. Encouraging the intake of low-sodium liquids such as coffee or tea.
- B: The nurse should encourage intake of high-sodium liquids to correct hyponatremia.
- A: The nurse must assess for nausea and malaise because these are clinical manifestations of hyponatremia.
- C: Neurologic status should be monitored to avoid neurologic complications.
- D: Tap water intake should be restricted for patients with hyponatremia.
9. Answer: A. Fruits such as bananas and apricots
- A: Bananas and apricots are rich in potassium.
- B: Green leafy vegetables are rich in iron.
- C: Milk and yogurt are rich in calcium.
- D: Nuts and legumes are rich in protein.
10. Answer: D. Tetany
- D: Decreased levels of calcium and magnesium leads to tetany.
- A: Anorexia is a manifestation of hypomagnesemia while nausea is a sign of hypercalcemia.
- B: Constipation is not a manifestation of hypocalcemia or hypomagnesemia.
- C: Lack of coordination is not a manifestation of hypocalcemia or hypomagnesemia.
- 8-Step Guide to ABG Analysis: Tic-Tac-Toe Method
- Homeostasis, Fluids and Electrolytes NCLEX Practice Quiz 1 (30 Items)
- Homeostasis, Fluids and Electrolytes NCLEX Practice Quiz 2 (30 Items)
- Homeostasis, Fluids and Electrolytes NCLEX Practice Quiz 3 (30 Items)
Recommended resources and books:
- Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
- Medical-Surgical Nursing: Assessment and Management of Clinical Problems
- Medical-Surgical Nursing: Patient-Centered Collaborative Care
- Saunders Comprehensive Review for the NCLEX-RN Examination
- Brunner & Suddarth’s Textbook of Medical-Surgical Nursing