FLUID BALANCE HESI RN EVOLVE
EXAMINATION
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.
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.
3. Which labs would the nurse expect the Healthcare Provider (HCP) to order?
(Choose all that apply)
A. BUN
B. Serum creatinine
C. Urine specific gravity and osmolality
D. Liver function panel
E. None of the above - ANSWER-A. BUN
B. Serum creatinine
C. Urine specific gravity and osmolality
, D. Liver function panel
Page 3
Assessment
In addition to obtaining the client's vital signs, the nurse performs additional
assessments.
1. For ongoing evaluation of the client's fluid volume status, which assessment data
is most important to obtain?
A. Urine color.
B. Capillary refill.
C. Body weight.
D. Skin turgor. - ANSWER-C. Body weight.
The client's daughter reports that her mother usually weighs about 137 lbs. and is 5
feet, 3 inches in height. The nurse weighs the client and obtains a measurement of
60 kg.
2. The nurse explains to the client's daughter that the client has lost approximately
how many pounds?
A. 3
B. 5
C. 4
D. 7 - ANSWER-B. 5
EXAMINATION
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.
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.
3. Which labs would the nurse expect the Healthcare Provider (HCP) to order?
(Choose all that apply)
A. BUN
B. Serum creatinine
C. Urine specific gravity and osmolality
D. Liver function panel
E. None of the above - ANSWER-A. BUN
B. Serum creatinine
C. Urine specific gravity and osmolality
, D. Liver function panel
Page 3
Assessment
In addition to obtaining the client's vital signs, the nurse performs additional
assessments.
1. For ongoing evaluation of the client's fluid volume status, which assessment data
is most important to obtain?
A. Urine color.
B. Capillary refill.
C. Body weight.
D. Skin turgor. - ANSWER-C. Body weight.
The client's daughter reports that her mother usually weighs about 137 lbs. and is 5
feet, 3 inches in height. The nurse weighs the client and obtains a measurement of
60 kg.
2. The nurse explains to the client's daughter that the client has lost approximately
how many pounds?
A. 3
B. 5
C. 4
D. 7 - ANSWER-B. 5
