HESI Fluid Balance

Question 1

Scenario: 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.

Question 2

Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when she changes position?

Answer 2

Blood pressure

Rationale: 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.

Question 3

The nurse plans to assess the client for orthostatic vital sign changes. Which action will the nurse take first?

Answer 3

Position the client in a supine position.

Rationale: 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.

Question 4

The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take?

Answer 4

Count the client’s radial pulse.

Rationale: Both the blood pressure and pulse rate are typically measured in each position: lying, sitting, and standing.

Question 5

Age-Related Risk Factors: THe nurse discusses factors that contributed to the client’s fluid volume deficit with her and her daughter, and receives orders for labs to be obtained.

Which problem occurs in older client’s and may have contributed to the fluid volume deficit the client is experiencing?

Answer 5

Decreased hepatic blood flow.

Rationale: 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.

Question 6

The nurse is aware that older clients often experience an increase in the amount of free, unbound drug molecules, which has the potential to increase the pharmacological effects of the drug.

Which lab test will the nurse monitor to determine if this may be a factor contributing to the client’s problem?

Answer 6

Serum protein

Rationale: 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.

Question 7

Which labs would the nurse expect the Healthcare Provider (HCP) to order?

Answer 7

BUN: Increased level could indicate renal disease or dehydration.

Serum creatinine: Increase indicates renal disease.

Urine specific gravity and osmolality: dehydration, reduced renal blood flow, and increase in ADH secretion elevate specific gravity. Overhydration, early renal disease, and inadequate ADH secretion reduce specific gravity.

Liver function panel: If a decrease in liver function occurs such as with aging or liver disease, a medication is usually eliminated more slowly, resulting in its accumulation. Patients are at risk for medication toxicity if organs that metabolize medications are not functioning correctly.

Question 8

In additional to obtaining the client’s vital signs, the nurse performs additional assessments.

For ongoing evaluation of the client’s fluid volume status, which assessment data is most important to obtain?

Answer 8

Body weight

Rationale: Daily weights provide the most important data about fluid volume status, so an initial weight upon admission must be obtained.

Question 9

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.

The nurse explains to the client’s daughter that the client has lost approximately how many pounds.

Answer 9

5

Rationale: 60 kg x 2.2 = 137 ibs. - 132 lbs. = 5 pounds. This represents an approximate weight loss of 5 pounds.

Question 10

THe nurse continues to assess the client and observes that the client’s skin tents when a fold of skin over her sternum is pinched.

What action should the nurse implement?

Answer 10

Document the presence of inelastic skin turgor.

Rationale: Skin turgor is best assessed in the older client by gently pinching a fold of skin over the sternum. Inelastic turgor is an expected finding in a client with a fluid volume deficit. Additional findings may include weakness, confusion, and tachycardia.

Question 11

The nurse starts an IV to administer fluids. The prescription states, “3% sodium chloride injection to infuse at 100 mL/hour.” THe client’s most recent serum sodium level is 135 mEq/L (135 mmol/L).

What action should the nurse take?

Answer 11

Notify the HCP and obtain an order for appropriate IV fluids.

Rationale: Three percent sodium chloride injection is a hypertonic solution, which will pull fluid from the interstitial and intracellular spaces into the bloodstream. It is usually prescribed for severe hyponatremia (sodium).

Question 12

A short while later, a prescription for sodium chloride 0.9% injection IV at 100mL/hour is received and daily labs including Liver Function Panel (LFP), Complete Metabolic Panel (CMP), Blood Urea Nitrogen (BUN), and Creatinine. The client’s primary nurse is at lunch, so another nurse hangs the solution. When checking the client, upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose and sodium chloride 0.9% injection is infusing at 125 mL/hour.

What action should the primary nurse implement?

Answer 12

Change the currently infusing solution to sodium chloride 0.9% injection and change the rate to 100 mL/hour.

Rationale: Two errors have occurred: the wrong solution and the wrong rate of administration. These errors should both be corrected.

Question 13

Legal consideration: Treatment Error. After hanging the correct IV solution at the correct rate of infusion, the primary nurse discusses the error with the nurse who hung the first IV solution. Together, the nurses complete a variance (incident) report.

What additional action should the primary nurse take?

Answer 13

Notify the healthcare provider of the error in treatment that occurred.

Rationale: Since the prescription was not initially followed, the healthcare provider should be notified incase a charge in the treatment plan is warranted.

Question 14

The nurse who made the errors is very upset about writing an occurrence report and states, “I’ve never made an error before. What if I get fired?”

What is the primary nurse’s best response?

Answer 14

Variance reports are used to find ways to prevent further errors.

Rationale: Variance reports are used by the risk management department of healthcare agencies to look for patterns that contribute to errors so that preventative measures can be instituted.

Question 15

Later that day, the client’s IV pump alarm sounds. The nurse notes that the IV is not infusing in the right antecubital area, and the alarm indicates an obstruction is present. The nurse determines that all the clamps are open and there are no kinks in the tubing.

Which intervention should the nurse take next?

Answer 15

Straighten the joint above the site.

Rationale: Obstruction is often caused by client movement, resulting in a bend in the client’s proximal joint. Therefore, this noninvasive measure should be the next action taken by the nurse.

Question 16

THe nurse resolves the obstruction, and the IV solution begins to infuse. The next day the nurse observes that the IV insertion site is inflamed and tender.

Which action should the nurse take?

Answer 16

Remove the IV and restart it in a different location.

Rationale: The client is experiencing phlebitis, which can lead to further complications if left untreated. Since the nurse has the responsibility to take action when IV site complications occur, the IV should be discontinued, action should be taken for the inflammation according to agency policy, and a new IV should be started at a different site.

Question 18

And taking output measurement. The client continues to receive sodium chloride 0.9% injection at the rate of 100 mL per hour. She is stronger and has started taking oral food and fluids as well. She receives a regular regular, no added salt diet. Her breakfast includes one cup of scrambled eggs, one bowl of oatmeal, a fresh, orange, apple juice, and a carton of milk.

Which items should be measured as fluid intake? (SATA)

Answer 18

Milk, apple juice

Question 19

Now that the client is taking oral fluids as well, what action should the nurse implement?

Answer 19

Continue the measurement of the clients fluid intake output.

Rationale: Since the client is still receiving a significant volume of IV fluids, she remains at risk for fluid volume alterations. The nurse may initiate and maintain in taking output measurement without a prescription from the healthcare provider in most facilities.

Question 20

Fluid volume excess. The nurses concerned that the client may develop fluid volume excess because the clients intake is greater than her output and both ankles and feet are swollen.

Which assessment is important for the nurse to perform?

Answer 20

Auscultate the clients breath sounds.

Fluid volume excess often causes abnormal breath sounds. Fluid collection in the lungs can impair oxygen exchange.

Question 21

The client has abnormal breast sounds, bilateral, pitting, edema, and jugular vein distention.

How should the nurse document this swollen ankles and feet?

Answer 21

4+ pitting edema present bilateral ankles and feet.

Rationale: This documentation concisely describes the degree of indentation present and its location.

Question 22

Further findings include oxygen saturation level of 90%, sum sodium of 140 mEq/L. Serum chloride 105 mEq/L, Albumin 4 g/dL, AST 30 U/L, and serum potassium of 3 mEq/L from daily labs.

The nurse reports to the health healthcare provider, her assessment and lab findings. Which laboratory result is critical and should the nurse have the HCP repeat back?

Answer 22

Potassium 3 mEq/L.

Rationale: the client potassium level is low and will need to be addressed by the HCP.

Question 23

The nurse reports the findings to the healthcare provider and receives several prescriptions, including stopping the IV fluids. Which prescription should the nurse question?

Answer 23

Potassium chloride 40 mEq PO

Rationale: Client, Sam, 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 attained from the healthcare provider. In addition, The patient has an order for potassium wasting diuretic.

Question 24

Pharmacology: diuretics
The clients fluid volume excess improves and the prescription for hydrochlorothiazide 12.5 mg PO daily is restarted.

Which lab values are most important for the nurse monitor?

Answer 24

Serum potassium.

Rationale: hydrochlorothiazide, potassium, wasting diuretic, may cause significant hypokalemia.

Magnesium.

Rationale: use of hydrochlorothiazide may also result in a decreased in magnesium and sodium, increased in sodium calcium and glucose.

Question 25

Medication administration.
Oral tablets, the HCP prescribes hydrochlorothiazide 12.5 mg PO daily. In preparing to administer the HCTZ, the nurse notes that the prescribed dose is 12.5 mg, and the tablet that arrives from the pharmacy is 25 mg.

What action should the nurse take?

Answer 25

Notify the pharmacist of the error.

Rationale: The pharmacist should split the medication if it does not come in the prescribed amount.

Question 26

Which identifiers are acceptable for the nurse to use when verifying the right client prior to medication or treatment administration?

Answer 26

Clients full name, and date of birth.

Rationale: two identifier should be used to verify that a medication will be administered to the right client by using either barcode scanning system, or at least two identifier, such as full name, and date of birth.

Question 27

Upon entering the clients room with the medication, the nurse checks the clients identification band. The client states you take care of me every day. Why do you keep looking at my identification?

What is the best response by the nurse?

Answer 27

This is a double check to ensure that no errors occur.

Rationale: this response provides the best client teaching. The client can participate in the plan of care more actively if explanations for interventions are provided.

Question 28

The clients fluid volume excess improves in the prescription for hydrochlorothiazide 12.5 mg PO is restarted. The client is ready to be discharged, the nurse provides client teaching related to the prescribed hydrochlorothiazide.

Which signs and symptoms of fluid deficit should the nurse include when educating client and her daughter prior to discharge?

Answer 28

Changes in mental status.

Rationale: cognitive impairment is associated with dehydration in an older adult.

Changes in urine output

Rationale: decreased renal, perfusion, and altered renal function can compromise the client fluid status.

Presence of tachycardia

Rationale: presence of tachycardia associated with dehydration in the older adult.

Longitudinal furrows on the tongue

Rationale: longitudinal fails on the tongue are indicative of dehydration.

Question 29

The nurse will emphasize the importance of taking this medication only once a day, on what schedule?

Answer 29

With breakfast.

Rationale: 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.

Question 30

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 and understanding of potassium-rich foods?

Answer 30

Whole grains, peanut butter, tuna.

Rationale: this shows that the client has an understanding of potassium, rich foods.

Question 31

Case outcome

The clients fluid balances are stored. She’s taking oral fluids. Well, her IV solution has been discontinued, and she has received client teaching about fluid balance, and the correct administration of her diuretic and verbalizes understanding. The nurse observes the client red demonstrate how to break medication tablet and she does so without difficulty. The client has discharged home, accompanied by her daughter.