HESI Fluid Balance Case Study Questions
and answers
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-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.
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 client's feet at the bedside. - ANSWER-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.
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-Count the client's radial pulse rate.
Rationale: Both the blood pressure and pulse rate are typically measured in each
position: lying, sitting, and standing.
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 often occurs in older clients 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-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.
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?
a. Serum creatinine
b. Serum protein
c. AST
d. BUN - ANSWER-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.
and answers
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-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.
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 client's feet at the bedside. - ANSWER-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.
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-Count the client's radial pulse rate.
Rationale: Both the blood pressure and pulse rate are typically measured in each
position: lying, sitting, and standing.
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 often occurs in older clients 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-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.
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?
a. Serum creatinine
b. Serum protein
c. AST
d. BUN - ANSWER-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.
