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.
Rationale: Orthostatic vital signs are measured in each position: lying, sitting,
standing. The client's vital signs are first assessed in the supine position so that
changes that occur when the client sits and stands can be determined.
The nurse takes the first blood pressure measurement. After recording the first
blood pressure measurement, what action will the nurse take?
- Count the client's radial pulse rate.
- Remove the blood pressure cuff.
- Help the client changes position.
- Assess for auscultatory gap. - ANSWER-Count the client's radial pulse rate.
, Rationale: Both the blood pressure and pulse rate are typically measured in each
position: lying, sitting, and standing.
In addition to obtaining Donna's vital signs, the nurse performs additional
assessments. - ANSWER-Assessment (Title)
For ongoing evaluation of Donna's fluid volume status, it is more important to
obtain which assessment data?
- Urine color.
- Capillary refill.
- Body weight.
- Skin turgor. - ANSWER-Body weight.
Rationale: Daily weights provide the most important data about fluid volume
status, so an initial weight upon admission must be obtained.
The nurse continues to assess the client and observes that Donna's skin tents
when a fold of skin over her sternum is pinched. - ANSWER-(Information)
What action should the nurse implement?
- Confirm this finding by pinching the skin on her hand.
- Notify the healthcare provider that the client is now retaining 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.
Rationale: Orthostatic vital signs are measured in each position: lying, sitting,
standing. The client's vital signs are first assessed in the supine position so that
changes that occur when the client sits and stands can be determined.
The nurse takes the first blood pressure measurement. After recording the first
blood pressure measurement, what action will the nurse take?
- Count the client's radial pulse rate.
- Remove the blood pressure cuff.
- Help the client changes position.
- Assess for auscultatory gap. - ANSWER-Count the client's radial pulse rate.
, Rationale: Both the blood pressure and pulse rate are typically measured in each
position: lying, sitting, and standing.
In addition to obtaining Donna's vital signs, the nurse performs additional
assessments. - ANSWER-Assessment (Title)
For ongoing evaluation of Donna's fluid volume status, it is more important to
obtain which assessment data?
- Urine color.
- Capillary refill.
- Body weight.
- Skin turgor. - ANSWER-Body weight.
Rationale: Daily weights provide the most important data about fluid volume
status, so an initial weight upon admission must be obtained.
The nurse continues to assess the client and observes that Donna's skin tents
when a fold of skin over her sternum is pinched. - ANSWER-(Information)
What action should the nurse implement?
- Confirm this finding by pinching the skin on her hand.
- Notify the healthcare provider that the client is now retaining fluid.
