HESI Case Study: Fluid Balance - Answered with Rationales

HESI Case Study: Fluid Balance - Answered with Rationales Meet the Client 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 Since Donna has fluid volume deficit, the nurse anticipates a decrease in which vital sign when Donna changes position? - Respiratory rate - Blood pressure - Temperature - Pulse rate 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. The nurse plans to assess Donna for orthostatic vital sign changes. Which action will the nurse take first? - Assist Donna to a standing position. - Position Donna in a supine position. - Elevate the head of Donna's bed. - Dangle Donna's feet at the bedside. Rationale: 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. The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take? - Count the client's radial pulse rate. - Remove the blood pressure cuff. - Help the client changes position. - Assess for auscultatory gap. Rationale: 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. For ongoing evaluation of Donna's fluid volume status, it is more important to obtain which assessment data? - Urine color. - Capillary refill. - Body weight. - Skin turgor. Rationale: Daily weights provide the most important data about fluid volume status, so an initial weight upon admission must be obtained. Information The nurse continues to assess the client and observes that Donna's skin tents when a fold of skin over her sternum is pinched. What action should the nurse implement? - Confirm this finding by pinching the skin on her hand. - Notify the healthcare provider that the client is now retaining fluid. - Advise Donna that the fluid deficit seems to be worsening. - Document the presence of inelastic skin turgor. Rationale: 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