2026 HESI FLUID BALANCE CASE STUDY
QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALES|| GRADED
A+|| LATEST UPDATE 2026 (GUARANTEED
PASS!!)
What action should the nurse implement?
A. Confirm this finding by pinching the skin on her hand.
B. Notify the healthcare provider that the client is now retaining fluid.
C. Advise Donna that the fluid deficit seems to be worsening.
D. Document the presence of inelastic skin turgor.
D. Document the presence of inelastic skin turgor.
NOTE Skin turgor is best assessed in the elderly by gently pinching a
fold of skin over the sternum. Inelastic turgor is an expected finding in a
client with fluid volume deficit. Additional findings may include
weakness, confusion, and tachycardia.
Math
Donna's daughter reports that her mother usually weights 137 lbs (62.14
kg) and is 5' 3" (160 cm) in height. The nurse weighs Donna and obtains
a measurement of 60 kg.
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.
Vital signs: Orthostatic Changes
1. Since Donna has fluid volume deficit, the nurse anticipates a decrease
in which vital sign when Donna changes position?
A. Respiratory rate
B. Blood pressure
C. Temperature
D. Pulse rate
B. Blood pressure
Note 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.
2. The nurse plans to assess Donna for orthostatic vital sign changes.
Which action will the nurse take first?
A. Assist Donna to a standing position.
B. Position Donna in a supine position.
C. Elevate the head of Donna's bed.
D. Dangle Donna's feet at the bedside.
, B. Position Donna in a supine position.
NOTE Orthostatic vital signs are measured in each position: lying,
sitting, 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.
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 changes position.
D. Assess for auscultatory gap.
A. Count the client's radial pulse rate.
NOTE Both the blood pressure and pulse rate are typically measured in
each position: lying, sitting, and standing.
Assessment
In addition to obtaining Donna's vital signs, the nurse performs
additional assessments.
4. For ongoing evaluation of Donna's fluid volume status, it is more
important to obtain which assessment data?
A. Urine color.
B. Capillary refill.
C. Body weight.
D. Skin turgor.
QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALES|| GRADED
A+|| LATEST UPDATE 2026 (GUARANTEED
PASS!!)
What action should the nurse implement?
A. Confirm this finding by pinching the skin on her hand.
B. Notify the healthcare provider that the client is now retaining fluid.
C. Advise Donna that the fluid deficit seems to be worsening.
D. Document the presence of inelastic skin turgor.
D. Document the presence of inelastic skin turgor.
NOTE Skin turgor is best assessed in the elderly by gently pinching a
fold of skin over the sternum. Inelastic turgor is an expected finding in a
client with fluid volume deficit. Additional findings may include
weakness, confusion, and tachycardia.
Math
Donna's daughter reports that her mother usually weights 137 lbs (62.14
kg) and is 5' 3" (160 cm) in height. The nurse weighs Donna and obtains
a measurement of 60 kg.
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.
Vital signs: Orthostatic Changes
1. Since Donna has fluid volume deficit, the nurse anticipates a decrease
in which vital sign when Donna changes position?
A. Respiratory rate
B. Blood pressure
C. Temperature
D. Pulse rate
B. Blood pressure
Note 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.
2. The nurse plans to assess Donna for orthostatic vital sign changes.
Which action will the nurse take first?
A. Assist Donna to a standing position.
B. Position Donna in a supine position.
C. Elevate the head of Donna's bed.
D. Dangle Donna's feet at the bedside.
, B. Position Donna in a supine position.
NOTE Orthostatic vital signs are measured in each position: lying,
sitting, 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.
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 changes position.
D. Assess for auscultatory gap.
A. Count the client's radial pulse rate.
NOTE Both the blood pressure and pulse rate are typically measured in
each position: lying, sitting, and standing.
Assessment
In addition to obtaining Donna's vital signs, the nurse performs
additional assessments.
4. For ongoing evaluation of Donna's fluid volume status, it is more
important to obtain which assessment data?
A. Urine color.
B. Capillary refill.
C. Body weight.
D. Skin turgor.
