Evolve Case Study - Fluid Balance Exam
questions and answers
Scenario:
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 2-3 times per day.
The label of the medication bottle that was brought to the hospital says,
"hydrochlorothiazide (HydroDIURIL).
Take 1 tablet daily".
Donna is admitted with fluid volume deficit. - ANSWER---
Since Donna has a 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
***Fluid volume deficit often causes orthostatic hypotension and tachycardia.
Because the client may experience dizziness and orthostatic hypotension, the
nurse should take additional safety precautions during this assessment.
* the ANSWER is NOT decreased pulse rate because a pt with orthostatic
hypotension is likely to experience an INCREASE in pulse rate upon standing in
response to a change in blood pressure.
The nurse plans to assess Donna for orthostatic vital sign changes. Which action
should the nurse take first?
- assist Donna to a standing position
- dangle Donna's feet at the bedside
- position Donna in a supine position
- elevate the head of Donna's bed - ANSWER-Position Donna to a supine position
*** orthostatic vital signs are measured in each position: lying, sitting, and
standing. The patient'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, which action should the nurse take?
-assess for auscultatory gap
-count the client's radial pulse rate
-remove the blood pressure cuff
-help the client change positions - ANSWER-Count the client's radial pulse rate.
****both the blood pressure AND pulse rate are typically measured in each
position: lying, sitting, and standing***
*the ANSWER is NOT remove the blood pressure cuff because after the cuff is
defaulted, it is left in the same position on the same arm for all 3 BP readings
*assessment for an auscultatory gap is done WHILE the BP measurement is being
taken
In addition to obtaining Donna's vital signs, the nurse performs additional
assessments.
For ongoing evaluation of Donna's fluid volume status, it is most important to
obtain which assessment data?
-urine color
questions and answers
Scenario:
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 2-3 times per day.
The label of the medication bottle that was brought to the hospital says,
"hydrochlorothiazide (HydroDIURIL).
Take 1 tablet daily".
Donna is admitted with fluid volume deficit. - ANSWER---
Since Donna has a 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
***Fluid volume deficit often causes orthostatic hypotension and tachycardia.
Because the client may experience dizziness and orthostatic hypotension, the
nurse should take additional safety precautions during this assessment.
* the ANSWER is NOT decreased pulse rate because a pt with orthostatic
hypotension is likely to experience an INCREASE in pulse rate upon standing in
response to a change in blood pressure.
The nurse plans to assess Donna for orthostatic vital sign changes. Which action
should the nurse take first?
- assist Donna to a standing position
- dangle Donna's feet at the bedside
- position Donna in a supine position
- elevate the head of Donna's bed - ANSWER-Position Donna to a supine position
*** orthostatic vital signs are measured in each position: lying, sitting, and
standing. The patient'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, which action should the nurse take?
-assess for auscultatory gap
-count the client's radial pulse rate
-remove the blood pressure cuff
-help the client change positions - ANSWER-Count the client's radial pulse rate.
****both the blood pressure AND pulse rate are typically measured in each
position: lying, sitting, and standing***
*the ANSWER is NOT remove the blood pressure cuff because after the cuff is
defaulted, it is left in the same position on the same arm for all 3 BP readings
*assessment for an auscultatory gap is done WHILE the BP measurement is being
taken
In addition to obtaining Donna's vital signs, the nurse performs additional
assessments.
For ongoing evaluation of Donna's fluid volume status, it is most important to
obtain which assessment data?
-urine color
