NU271 HESI Case Study: Fluid Balance
(week 10) Updated 2024-2025
Client's serum potassium is low. She needs potassium replacement via IV solution
instead of the PO route. A prescription for potassium chloride diluted in an IV solution to
be administered over several hours should be obtained from the healthcare provider. In
addition, the patient has an order for potassium wasting diuretic.
Which lab values are most important for the nurse to monitor? (Select all that apply.) -
CORRECT ANSWERS-Serum potassium (Hydrochlorothiazide, a potassium-wasting
diuretic, may cause significant hypokalemia.)
Magnesium. (Use of hydrochlorothiazide may also result in a decrease in serum
magnesium and sodium and an increase in serum calcium and glucose.)
Which action should the nurse take? - CORRECT ANSWERS-Notify the pharmacist of
the error.
-
The pharmacist should split the medication if it does not come in the prescribed amount.
Which identifiers are acceptable for the nurse to use when verifying the right client prior
to medication or treatment administration? (Select all that apply.) - CORRECT
ANSWERS-Client full name., Date of birth.
What is the best response by the nurse? - CORRECT ANSWERS-"This is a double-
check to ensure that no errors occur."
-
This response provides the best client teaching. The client can participate in the plan of
care more actively if explanations for interventions are provided.
Which signs and symptoms of fluid volume deficit should the nurse include when
educating the client and her daughter prior to discharge? (Select all that apply.) -
CORRECT ANSWERS-Changes in mental status., Change in urine output., Presence
of tachycardia.Longitudinal furrows on the tongue.
The nurse will emphasize the importance of taking this medication only once a day, on
what schedule? - CORRECT ANSWERS-With breakfast.
-
To reduce the likelihood of nocturia, the client should be instructed to take diuretics in
the morning. Additionally, taking the medication with food may reduce adverse effects,
such as nausea.
Since the client is receiving a diuretic that contributes to the loss of potassium, the
nurse must provide dietary teaching. Which foods selected by the client indicate an
, understanding of potassium-rich foods? (Select all that apply.) - CORRECT ANSWERS-
Whole grains, Peanut butter, Tuna
Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital
sign when she changes position? - CORRECT ANSWERS-Blood pressure.
-
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 the client for orthostatic vital sign changes. Which action will
the nurse take first? - CORRECT ANSWERS-Position the client in a supine position.
-
Orthostatic vital signs are measured in each position: lying, sitting, and 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? - CORRECT ANSWERS-Count
the client's radial pulse rate.
-
Both the blood pressure and pulse rate are typically measured in each position: lying,
sitting, and standing.
Which problem often occurs in older clients and may have contributed to the fluid
volume deficit the client is experiencing? - CORRECT ANSWERS-Decreased hepatic
blood flow.
-
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.
Which lab test will the nurse monitor to determine if this may be a factor contributing to
the client's problem? - CORRECT ANSWERS-Serum protein.
-
Drug molecules may be distributed throughout the body bound to plasma protein
molecules. A decrease in serum protein levels is an indication that there may be an
increase in free, unbound drug molecules in the bloodstream.
Which labs would the nurse expect the Healthcare Provider (HCP) to order? (Choose all
that apply.) - CORRECT ANSWERS-BUN, Serum creatinine, Urine specific gravity and
osmolality, Liver function panel
-
For ongoing evaluation of the client's fluid volume status, which assessment data is
most important to obtain? - CORRECT ANSWERS-Body weight.
-
(week 10) Updated 2024-2025
Client's serum potassium is low. She needs potassium replacement via IV solution
instead of the PO route. A prescription for potassium chloride diluted in an IV solution to
be administered over several hours should be obtained from the healthcare provider. In
addition, the patient has an order for potassium wasting diuretic.
Which lab values are most important for the nurse to monitor? (Select all that apply.) -
CORRECT ANSWERS-Serum potassium (Hydrochlorothiazide, a potassium-wasting
diuretic, may cause significant hypokalemia.)
Magnesium. (Use of hydrochlorothiazide may also result in a decrease in serum
magnesium and sodium and an increase in serum calcium and glucose.)
Which action should the nurse take? - CORRECT ANSWERS-Notify the pharmacist of
the error.
-
The pharmacist should split the medication if it does not come in the prescribed amount.
Which identifiers are acceptable for the nurse to use when verifying the right client prior
to medication or treatment administration? (Select all that apply.) - CORRECT
ANSWERS-Client full name., Date of birth.
What is the best response by the nurse? - CORRECT ANSWERS-"This is a double-
check to ensure that no errors occur."
-
This response provides the best client teaching. The client can participate in the plan of
care more actively if explanations for interventions are provided.
Which signs and symptoms of fluid volume deficit should the nurse include when
educating the client and her daughter prior to discharge? (Select all that apply.) -
CORRECT ANSWERS-Changes in mental status., Change in urine output., Presence
of tachycardia.Longitudinal furrows on the tongue.
The nurse will emphasize the importance of taking this medication only once a day, on
what schedule? - CORRECT ANSWERS-With breakfast.
-
To reduce the likelihood of nocturia, the client should be instructed to take diuretics in
the morning. Additionally, taking the medication with food may reduce adverse effects,
such as nausea.
Since the client is receiving a diuretic that contributes to the loss of potassium, the
nurse must provide dietary teaching. Which foods selected by the client indicate an
, understanding of potassium-rich foods? (Select all that apply.) - CORRECT ANSWERS-
Whole grains, Peanut butter, Tuna
Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital
sign when she changes position? - CORRECT ANSWERS-Blood pressure.
-
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 the client for orthostatic vital sign changes. Which action will
the nurse take first? - CORRECT ANSWERS-Position the client in a supine position.
-
Orthostatic vital signs are measured in each position: lying, sitting, and 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? - CORRECT ANSWERS-Count
the client's radial pulse rate.
-
Both the blood pressure and pulse rate are typically measured in each position: lying,
sitting, and standing.
Which problem often occurs in older clients and may have contributed to the fluid
volume deficit the client is experiencing? - CORRECT ANSWERS-Decreased hepatic
blood flow.
-
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.
Which lab test will the nurse monitor to determine if this may be a factor contributing to
the client's problem? - CORRECT ANSWERS-Serum protein.
-
Drug molecules may be distributed throughout the body bound to plasma protein
molecules. A decrease in serum protein levels is an indication that there may be an
increase in free, unbound drug molecules in the bloodstream.
Which labs would the nurse expect the Healthcare Provider (HCP) to order? (Choose all
that apply.) - CORRECT ANSWERS-BUN, Serum creatinine, Urine specific gravity and
osmolality, Liver function panel
-
For ongoing evaluation of the client's fluid volume status, which assessment data is
most important to obtain? - CORRECT ANSWERS-Body weight.
-
