Page 1?? Exam Q&A 2026/2027 | #Newest Page 1 of 168 ::Detailed Rationales, Study Guide & Review Notes |1
HESI Case Study: Fluid Balance Questions
with complete answers solution
Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital
sign when she changes position? - ANSWER-Blood pressure
The nurse plans to assess the client for orthostatic vital sign changes. Which action will
the nurse take first? - ANSWER-Position the client in a supine position.
Which problem often occurs in older clients and may have contributed to the fluid
volume deficit the client is experiencing? - ANSWER-Decreased hepatic blood flow.
Which lab test will the nurse monitor to determine if this may be a factor contributing to
the client's problem? - ANSWER-Serum protein
Which labs would the nurse expect the HCP to order? - ANSWER-BUN, Serum
creatinine, urine specific gravity & osmolarity, liver function panel
For ongoing evaluation of the clients fluid volume status, which assessment data is
most important to obtain? - ANSWER-Body weight
The nurse explains to the client's daughter that the client has lost approximately how
many pounds? - ANSWER-5
What action should the nurse implement? - ANSWER-Document the presence of
inelastic skin turgor.
What action should the nurse take? - ANSWER-Notify the HCP and obtain an order for
appropriate IV fluids.
What additional action should the primary nurse take? - ANSWER-Notify the HCP of the
error in treatment that occurred?
What is the primary nurses's best response? - ANSWER-Variance reports are used to
find ways to prevent future errors.
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,Page 2?? Exam Q&A 2026/2027 | #Newest Page 2 of 168 ::Detailed Rationales, Study Guide & Review Notes |2
What action should the primary nurse implement? - ANSWER-Change the currently
infusing solution to sodium chloride 0.9% injection and change the rate to 100mL/hr.
Which intervention should the nurse take next? - ANSWER-Straighten the joint above
the site.
Which action should the nurse take? - ANSWER-Remove the IV and restart in a
different location.
Which items should be measured as fluid intake? - ANSWER-Milk, Apple juice
Now that the client is taking oral fluids well, which action should the nurse implement? -
ANSWER-Continue the measurement of the client's intake and output
Which assessment is important for the nurse to perform? - ANSWER-Auscultate the
client's breath sounds
How should the nurse document the swollen ankles & feet? - ANSWER-4+ pitting
edema present bilateral ankles & feet
The nurse reports tot the HCP her assessment and lab findings. Which lab result HCP
repeat back? - ANSWER-Potassium 3 mEq/L
The nurse reports the finding to the HCP and receives several prescriptions including...
which prescription should the nurse question? - ANSWER-Potassium chloride 40 mEq
PO
Which lab values are most important for the nurse to monitor? - ANSWER-Serum
potassium, magnesium
DIDN"T GET THE ACTUAL QUESTION ON MY SS - ANSWER-Change in mental
status, change in urine output, presence of tachycardia, longitudinal furrows of the
tongue
The nurse will emphasize the importance of taking med only once a day, on what
schedule? - ANSWER-With breakfast
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Since the client is receiving a diuretic that contributes to the loss of potassium, the
nurse must provide dietary teaching.... selected by the client indicate an understanding
of potassium-rich foods? - ANSWER-Whole grains, peanut butter, tuna
The nurse takes the first bp measurement? After recording the first BP, which action
should the nurse take next? - ANSWER-Count the client's radial pulse rate.
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, Page 4?? Exam Q&A 2026/2027 | #Newest Page 4 of 168 ::Detailed Rationales, Study Guide & Review Notes |4
HESI Case Study: Fluid Balance Test
questions with complete solution
Donna King is an 80 year old female with coronary artery disease and hypertension.
Her daughter brought her to the Emergency Department because she has become
increasingly weak and confused and was found by a neighbor wandering her
neighborhood unable to locate her home. Donna'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." Donna is admitted with fluid volume deficit. -
ANSWER-Meet the Client (Title)
*Vital signs: Orthostatic Changes*
Since Donna has fluid volume deficit, the nurse anticipates a decrease in which vital
sign when Donna changes position?
- Respiratory rate
- Blood pressure
- Temperature
- Pulse rate - ANSWER-Blood pressure
Rationale: Fluid volume deficit often causes orthostatic hypotension and tachycardia.
Because the client may experience dizziness with orthostatic hypotension, the nurse
should take additional safety precautions during this assessment.
The nurse plans to assess Donna for orthostatic vital sign changes. Which action will
the nurse take first?
- Assist Donna to a standing position.
- Position Donna in a supine position.
- Elevate the head of Donna's bed.
- Dangle Donna's feet at the bedside. - ANSWER-Position Donna in a supine position.
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HESI Case Study: Fluid Balance Questions
with complete answers solution
Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital
sign when she changes position? - ANSWER-Blood pressure
The nurse plans to assess the client for orthostatic vital sign changes. Which action will
the nurse take first? - ANSWER-Position the client in a supine position.
Which problem often occurs in older clients and may have contributed to the fluid
volume deficit the client is experiencing? - ANSWER-Decreased hepatic blood flow.
Which lab test will the nurse monitor to determine if this may be a factor contributing to
the client's problem? - ANSWER-Serum protein
Which labs would the nurse expect the HCP to order? - ANSWER-BUN, Serum
creatinine, urine specific gravity & osmolarity, liver function panel
For ongoing evaluation of the clients fluid volume status, which assessment data is
most important to obtain? - ANSWER-Body weight
The nurse explains to the client's daughter that the client has lost approximately how
many pounds? - ANSWER-5
What action should the nurse implement? - ANSWER-Document the presence of
inelastic skin turgor.
What action should the nurse take? - ANSWER-Notify the HCP and obtain an order for
appropriate IV fluids.
What additional action should the primary nurse take? - ANSWER-Notify the HCP of the
error in treatment that occurred?
What is the primary nurses's best response? - ANSWER-Variance reports are used to
find ways to prevent future errors.
Page 1 of 168 Page 1 of 168 Page 1 of 168
,Page 2?? Exam Q&A 2026/2027 | #Newest Page 2 of 168 ::Detailed Rationales, Study Guide & Review Notes |2
What action should the primary nurse implement? - ANSWER-Change the currently
infusing solution to sodium chloride 0.9% injection and change the rate to 100mL/hr.
Which intervention should the nurse take next? - ANSWER-Straighten the joint above
the site.
Which action should the nurse take? - ANSWER-Remove the IV and restart in a
different location.
Which items should be measured as fluid intake? - ANSWER-Milk, Apple juice
Now that the client is taking oral fluids well, which action should the nurse implement? -
ANSWER-Continue the measurement of the client's intake and output
Which assessment is important for the nurse to perform? - ANSWER-Auscultate the
client's breath sounds
How should the nurse document the swollen ankles & feet? - ANSWER-4+ pitting
edema present bilateral ankles & feet
The nurse reports tot the HCP her assessment and lab findings. Which lab result HCP
repeat back? - ANSWER-Potassium 3 mEq/L
The nurse reports the finding to the HCP and receives several prescriptions including...
which prescription should the nurse question? - ANSWER-Potassium chloride 40 mEq
PO
Which lab values are most important for the nurse to monitor? - ANSWER-Serum
potassium, magnesium
DIDN"T GET THE ACTUAL QUESTION ON MY SS - ANSWER-Change in mental
status, change in urine output, presence of tachycardia, longitudinal furrows of the
tongue
The nurse will emphasize the importance of taking med only once a day, on what
schedule? - ANSWER-With breakfast
Page 2 of 168 Page 2 of 168 Page 2 of 168
,Page 3?? Exam Q&A 2026/2027 | #Newest Page 3 of 168 ::Detailed Rationales, Study Guide & Review Notes |3
Since the client is receiving a diuretic that contributes to the loss of potassium, the
nurse must provide dietary teaching.... selected by the client indicate an understanding
of potassium-rich foods? - ANSWER-Whole grains, peanut butter, tuna
The nurse takes the first bp measurement? After recording the first BP, which action
should the nurse take next? - ANSWER-Count the client's radial pulse rate.
Page 3 of 168 Page 3 of 168 Page 3 of 168
, Page 4?? Exam Q&A 2026/2027 | #Newest Page 4 of 168 ::Detailed Rationales, Study Guide & Review Notes |4
HESI Case Study: Fluid Balance Test
questions with complete solution
Donna King is an 80 year old female with coronary artery disease and hypertension.
Her daughter brought her to the Emergency Department because she has become
increasingly weak and confused and was found by a neighbor wandering her
neighborhood unable to locate her home. Donna'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." Donna is admitted with fluid volume deficit. -
ANSWER-Meet the Client (Title)
*Vital signs: Orthostatic Changes*
Since Donna has fluid volume deficit, the nurse anticipates a decrease in which vital
sign when Donna changes position?
- Respiratory rate
- Blood pressure
- Temperature
- Pulse rate - ANSWER-Blood pressure
Rationale: Fluid volume deficit often causes orthostatic hypotension and tachycardia.
Because the client may experience dizziness with orthostatic hypotension, the nurse
should take additional safety precautions during this assessment.
The nurse plans to assess Donna for orthostatic vital sign changes. Which action will
the nurse take first?
- Assist Donna to a standing position.
- Position Donna in a supine position.
- Elevate the head of Donna's bed.
- Dangle Donna's feet at the bedside. - ANSWER-Position Donna in a supine position.
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