Questions with Certified Solutions
An older adult with coronary artery disease and hypertension was brought to the Emergency
Department by her daughter because she has become increasingly weak and confused. The client was
found by a neighbor wandering her neighborhood unable to locate her home. The client'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. Take 1 tablet daily." The
client is admitted with fluid volume deficit. - Answer
Page 1
Vital Signs: Orthostatic Changes
1. Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when
she changes position?
A. Respiratory Rate
B. Blood Pressure.
C. Temperature.
D. Pulse Rate - Answer B. Blood Pressure
2. The nurse plans to assess the client for orthostatic vital sign changes. Which action will the nurse take
first?
A. Assist the client to a standing position.
B. Position the client in a supine position.
C. Elevate the head of the client's bed.
D. Dangle the clients feet at the bedside. - Answer B. Position the client in a supine position.
3. The nurse takes the first blood pressure measurement. After recording the first blood pressure
measurement, what action will the nurse take?
, A. Count the client's radial pulse rate.
B. Remove the blood pressure cuff.
C. Help the client change positions.
D. Assess for an auscultatory gap. - Answer A. Count the client's radial pulse.
Page 2
Age-related Risk Factors
The nurse discusses factors that contributed to the client's fluid volume deficit with her daughter, and
receives orders for labs to be obtained.
1. Which problem often occurs in older client's and may have contributed to the fluid volume deficit the
client is experiencing?
A. Decreased hepatic blood flow.
B. Decreased drug absorption.
C. Decreased drug half-life.
D. Decreased GI acidity. - Answer A. Decreased hepatic blood flow.
Rationale: Decreased hepatic blood flow commonly occurs in older clients. This decreases drug
metabolism, which allows drugs to remain in the body longer and produces a greater drug effect.
The nurse is aware that older clients often experience an increased in the amount of free, unbound drug
molecules, which has the potential to increase the pharmacological effects of the drug.
2. Which lab test will the nurse monitor to determine if this may be a factor contributing to the client's
problem?
A. Serum creatinine.
B. Serum protein.
C. AST.
D. BUN. - Answer B. Serum Protein.