Case study: Fluid Balance Questions with verified answers

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. - ANSWERSince Donna has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Donna changes position? - ANSWER-Blood pressure The nurse plans to assess Donna for orthostatic vital sign changes. Which action will the nurse take first? - ANSWER-Position Donna in a supine position The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take? - ANSWER-Count the client's radial pulse rate For ongoing evaluation of Donna's fluid volume status, it is more important to obtain which assessment data? - ANSWER-Body weight What action should the nurse implement? - ANSWER-Document the presence of inelastic skin