Fluid Balance- HESI Case Study: Questions With Clear
Solutions
Clara Bidalchi is an 86-year-old female with hypertension. Her daughter
brought her to the Emergency Department because she has become
increasingly weak and confused. Clara's daughter tells the nurse that her
mother takes a "water pill" for her blood pressure 2 or 3 times a day. The label
on the medication bottle that she brought to the hospital states,
"hydrochlorothiazide (HydroDIURIL). Take 1 tablet daily." Clara is admitted
with fluid volume deficit.
The nurse plans to assess Clara for orthostatic vital sign changes.
What action will the nurse take first? Accurate Answer:- Position Clara
in a supine position
Orthostatic vital signs are measured in three different positions: lying sitting
and standing. So placing pt in supine position should be first
The nurse takes the first blood pressure measurement.
After recording the first blood pressure measurement, what action will the
nurse take? Accurate Answer:- Count the client's radial pulse rate
Both the BP and pulse rate are typically measured in each position lying,
sitting and standing
Since Clara has a fluid volume deficit, the nurse anticipates a decrease in
which vital sign when Clara moves from a lying to a standing position?
Accurate Answer:- Blood pressure.
Fluid volume deficit often occurs with orthostatic hypotension and
tachycardia. Because the client may experience diziness with orthostatic
hypotension the nurse should take additional safety precautions
In addition to obtaining Clara's vital signs, the nurse performs additional
assessments.
, For ongoing evaluation of Clara's fluid volume status, it is most important to
obtain which assessment data? Accurate Answer:- Body weight
Daily weights provide the most important dataabout fluid volume status
The nurse continues to assess the client and observes that Clara's skin tents
when a fold of skin over her sternum is pinched.
What action should the nurse implement? Accurate Answer:- Document
the presence of inelastic skin turgor
Skin turgor is best assessed in the elderly by gently pinching a fold of skin
over the sternum.
Clara's daughter reports that her mother usually weighs about 150 lbs. and is
5 feet, 4 inches in height. The nurse weighs Clara and obtains a measurement
of 65 kg.
The nurse explains to Clara's daughter that Clara has lost approximately how
many pounds? Accurate Answer:- 7
65 kg x 2.2 = 143. 150 lbs.-143= 7lbs
The nurse then explains that Clara's weight loss represents approximately
how many liters of fluid loss? Accurate Answer:- 3
7/2.2=3.2 kg
(1 kg is equivalent to 1 L)
The nurse discusses factors that contributed to Clara's fluid volume deficit
with Clara and her daughter.
Which problem often occurs in the elderly and may have contributed to the
fluid volume deficit Clara is experiencing? Accurate Answer:-
Decreased hepatic blood flow
decreased hepatic flow commonly occurs in the elderly. This decreases drug
metabolism, which allows drugs to remain in the body longer and produces a
greater drug effect
Solutions
Clara Bidalchi is an 86-year-old female with hypertension. Her daughter
brought her to the Emergency Department because she has become
increasingly weak and confused. Clara's daughter tells the nurse that her
mother takes a "water pill" for her blood pressure 2 or 3 times a day. The label
on the medication bottle that she brought to the hospital states,
"hydrochlorothiazide (HydroDIURIL). Take 1 tablet daily." Clara is admitted
with fluid volume deficit.
The nurse plans to assess Clara for orthostatic vital sign changes.
What action will the nurse take first? Accurate Answer:- Position Clara
in a supine position
Orthostatic vital signs are measured in three different positions: lying sitting
and standing. So placing pt in supine position should be first
The nurse takes the first blood pressure measurement.
After recording the first blood pressure measurement, what action will the
nurse take? Accurate Answer:- Count the client's radial pulse rate
Both the BP and pulse rate are typically measured in each position lying,
sitting and standing
Since Clara has a fluid volume deficit, the nurse anticipates a decrease in
which vital sign when Clara moves from a lying to a standing position?
Accurate Answer:- Blood pressure.
Fluid volume deficit often occurs with orthostatic hypotension and
tachycardia. Because the client may experience diziness with orthostatic
hypotension the nurse should take additional safety precautions
In addition to obtaining Clara's vital signs, the nurse performs additional
assessments.
, For ongoing evaluation of Clara's fluid volume status, it is most important to
obtain which assessment data? Accurate Answer:- Body weight
Daily weights provide the most important dataabout fluid volume status
The nurse continues to assess the client and observes that Clara's skin tents
when a fold of skin over her sternum is pinched.
What action should the nurse implement? Accurate Answer:- Document
the presence of inelastic skin turgor
Skin turgor is best assessed in the elderly by gently pinching a fold of skin
over the sternum.
Clara's daughter reports that her mother usually weighs about 150 lbs. and is
5 feet, 4 inches in height. The nurse weighs Clara and obtains a measurement
of 65 kg.
The nurse explains to Clara's daughter that Clara has lost approximately how
many pounds? Accurate Answer:- 7
65 kg x 2.2 = 143. 150 lbs.-143= 7lbs
The nurse then explains that Clara's weight loss represents approximately
how many liters of fluid loss? Accurate Answer:- 3
7/2.2=3.2 kg
(1 kg is equivalent to 1 L)
The nurse discusses factors that contributed to Clara's fluid volume deficit
with Clara and her daughter.
Which problem often occurs in the elderly and may have contributed to the
fluid volume deficit Clara is experiencing? Accurate Answer:-
Decreased hepatic blood flow
decreased hepatic flow commonly occurs in the elderly. This decreases drug
metabolism, which allows drugs to remain in the body longer and produces a
greater drug effect
