HESI FLUID BALANCE CASE EXAM
2026/2027 ACTUAL EXAM STUDY GUIDE
COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED
A+||NEWEST VERSION
When Donna was first admitted, the HCP did not include intake and output
measurement in the initial prescriptions, but the primary nurse initiated this
assessment activity. - ANSWER (Information)
Now that Donna is taking oral fluids well, what action should the nurse
implement?
- Notify the healthcare provider that a prescription to continue intake and output
measurement is needed.
- Continue the measurement of the client's fluid intake and output.
- Stop measuring the client's fluid intake and output as long as she takes oral fluids.
- Measure the client's fluid output, but discontinue measuring fluid intake. -
ANSWER Continue the measurement of the client's fluid intake and output.
Rationale: Since Donna is still receiving a significant volume of IV fluids, she
remains at risk for fluid volume alterations. The nurse may initiate and maintain
intake and output measurement without a prescription from the HCP.
,Donna's intake and output measurements indicate her intake is greater than her
output. The nurse is concerned that Donna may develop fluid volume excess. -
ANSWER Fluid Volume Excess (Title)
Which assessment is important for the nurse to perform?
- Auscultate the client's breath sounds.
- Measure the client's tympanic temperature.
- Compare the client's muscle strength bilaterally.
- Ask the client if she is experiencing any syncope. - ANSWER Auscultate the
client's breath sounds.
Rationale: Fluid volume excess often causes abnormal breath sounds. Fluid
collection in the lungs can impair oxygen exchange and result in hypoxemia.
The nurse also observes that Donna's feet and ankles are swollen. When the nurse
presses a finger over the client's ankle (bony prominence), an 8 mm indentation
appears. - ANSWER (Information)
How will the nurse document this finding?
- Gross edema in the lower extremities.
- 4+ pitting edema present around ankles and feet.
- Stage 1 pressure ulcer forming due to ankle edema.
- Blanching and induration are present bilaterally. - ANSWER 4+ pitting edema
present around ankles and feet.
,Rationale: This documentation concisely describes the degree of indentation
present and its location.
Donna has abnormal breath sounds, bilateral pitting edema, and jugular vein
distention. - ANSWER (Information)
Which change in Donna's pulse will the nurse anticipate?
- Increase in rate and volume.
- Decrease in rate and volume.
- Increase in rate, but no change in the volume.
- Decrease in rate, but no change in the volume. - ANSWER Increase in rate and
volume.
Rationale: As fluid volume increases to the point of fluid volume excess, the client
will develop tachycardia (increase in rate) and a bounding pulse (increase in
volume).
Further findings include oxygen saturation level of 90%, serum sodium of 140
mEq/L, serum chloride 105 mmil/L, albumin 4 g/dL, AST 30 IU/L, and serum
potassium of 3 mEq/L. - ANSWER (Information)
The nurse reviews the client's laboratory results. Which laboratory result is critical
and should be reported to the HCP?
, - Sodium 140.
- Chloride 105.
- Albumin 4.
- Potassium 3. - ANSWER Potassium 3.
Rationale: The client's potassium level is low and will need to be addressed by the
HCP.
The nurse reports the findings to the healthcare provider and receives several
prescriptions. Which prescriptions should the nurse question?
- Furosemide (Lasix) 40 mg IV push now.
- Potassium chloride 40 mEq PO.
- Decrease the Normal Saline to KVO.
- Administer oxygen per nasal cannula at 2 L/minute. - ANSWER Potassium
chloride 40 mEq PO.
Rationale: Donna'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
HCP.
Donna's fluid volume excess improves and the prescription for
hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted. -
ANSWER Pharmacology: Diuretics (Title)
2026/2027 ACTUAL EXAM STUDY GUIDE
COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED
A+||NEWEST VERSION
When Donna was first admitted, the HCP did not include intake and output
measurement in the initial prescriptions, but the primary nurse initiated this
assessment activity. - ANSWER (Information)
Now that Donna is taking oral fluids well, what action should the nurse
implement?
- Notify the healthcare provider that a prescription to continue intake and output
measurement is needed.
- Continue the measurement of the client's fluid intake and output.
- Stop measuring the client's fluid intake and output as long as she takes oral fluids.
- Measure the client's fluid output, but discontinue measuring fluid intake. -
ANSWER Continue the measurement of the client's fluid intake and output.
Rationale: Since Donna is still receiving a significant volume of IV fluids, she
remains at risk for fluid volume alterations. The nurse may initiate and maintain
intake and output measurement without a prescription from the HCP.
,Donna's intake and output measurements indicate her intake is greater than her
output. The nurse is concerned that Donna may develop fluid volume excess. -
ANSWER Fluid Volume Excess (Title)
Which assessment is important for the nurse to perform?
- Auscultate the client's breath sounds.
- Measure the client's tympanic temperature.
- Compare the client's muscle strength bilaterally.
- Ask the client if she is experiencing any syncope. - ANSWER Auscultate the
client's breath sounds.
Rationale: Fluid volume excess often causes abnormal breath sounds. Fluid
collection in the lungs can impair oxygen exchange and result in hypoxemia.
The nurse also observes that Donna's feet and ankles are swollen. When the nurse
presses a finger over the client's ankle (bony prominence), an 8 mm indentation
appears. - ANSWER (Information)
How will the nurse document this finding?
- Gross edema in the lower extremities.
- 4+ pitting edema present around ankles and feet.
- Stage 1 pressure ulcer forming due to ankle edema.
- Blanching and induration are present bilaterally. - ANSWER 4+ pitting edema
present around ankles and feet.
,Rationale: This documentation concisely describes the degree of indentation
present and its location.
Donna has abnormal breath sounds, bilateral pitting edema, and jugular vein
distention. - ANSWER (Information)
Which change in Donna's pulse will the nurse anticipate?
- Increase in rate and volume.
- Decrease in rate and volume.
- Increase in rate, but no change in the volume.
- Decrease in rate, but no change in the volume. - ANSWER Increase in rate and
volume.
Rationale: As fluid volume increases to the point of fluid volume excess, the client
will develop tachycardia (increase in rate) and a bounding pulse (increase in
volume).
Further findings include oxygen saturation level of 90%, serum sodium of 140
mEq/L, serum chloride 105 mmil/L, albumin 4 g/dL, AST 30 IU/L, and serum
potassium of 3 mEq/L. - ANSWER (Information)
The nurse reviews the client's laboratory results. Which laboratory result is critical
and should be reported to the HCP?
, - Sodium 140.
- Chloride 105.
- Albumin 4.
- Potassium 3. - ANSWER Potassium 3.
Rationale: The client's potassium level is low and will need to be addressed by the
HCP.
The nurse reports the findings to the healthcare provider and receives several
prescriptions. Which prescriptions should the nurse question?
- Furosemide (Lasix) 40 mg IV push now.
- Potassium chloride 40 mEq PO.
- Decrease the Normal Saline to KVO.
- Administer oxygen per nasal cannula at 2 L/minute. - ANSWER Potassium
chloride 40 mEq PO.
Rationale: Donna'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
HCP.
Donna's fluid volume excess improves and the prescription for
hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted. -
ANSWER Pharmacology: Diuretics (Title)
