Evolve Case Study - Fluid Balance Exam
questions and answers
Scenario:
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 2-3 times per day.
The label of the medication bottle that was brought to the hospital says,
"hydrochlorothiazide (HydroDIURIL).
Take 1 tablet daily".
Donna is admitted with fluid volume deficit. - ANSWER---
Since Donna has a fluid volume deficit, the nurse anticipates a decrease in which vital
sign when Donna changes position?
- respiratory rate
- blood pressure
- temperature
- pulse rate - ANSWER-Blood pressure
***Fluid volume deficit often causes orthostatic hypotension and tachycardia. Because
the client may experience dizziness and orthostatic hypotension, the nurse should take
additional safety precautions during this assessment.
* the answer is NOT decreased pulse rate because a pt with orthostatic hypotension is
likely to experience an INCREASE in pulse rate upon standing in response to a change
in blood pressure.
, The nurse plans to assess Donna for orthostatic vital sign changes. Which action should
the nurse take first?
- assist Donna to a standing position
- dangle Donna's feet at the bedside
- position Donna in a supine position
- elevate the head of Donna's bed - ANSWER-Position Donna to a supine position
*** orthostatic vital signs are measured in each position: lying, sitting, and standing. The
patient'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, which action should the nurse take?
-assess for auscultatory gap
-count the client's radial pulse rate
-remove the blood pressure cuff
-help the client change positions - ANSWER-Count the client's radial pulse rate.
****both the blood pressure AND pulse rate are typically measured in each position:
lying, sitting, and standing***
*the answer is NOT remove the blood pressure cuff because after the cuff is defaulted,
it is left in the same position on the same arm for all 3 BP readings
*assessment for an auscultatory gap is done WHILE the BP measurement is being
taken
In addition to obtaining Donna's vital signs, the nurse performs additional assessments.
For ongoing evaluation of Donna's fluid volume status, it is most important to obtain
which assessment data?
-urine color
-capillary refill
-body weight
-skin turgor - ANSWER-Body weight.
questions and answers
Scenario:
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 2-3 times per day.
The label of the medication bottle that was brought to the hospital says,
"hydrochlorothiazide (HydroDIURIL).
Take 1 tablet daily".
Donna is admitted with fluid volume deficit. - ANSWER---
Since Donna has a fluid volume deficit, the nurse anticipates a decrease in which vital
sign when Donna changes position?
- respiratory rate
- blood pressure
- temperature
- pulse rate - ANSWER-Blood pressure
***Fluid volume deficit often causes orthostatic hypotension and tachycardia. Because
the client may experience dizziness and orthostatic hypotension, the nurse should take
additional safety precautions during this assessment.
* the answer is NOT decreased pulse rate because a pt with orthostatic hypotension is
likely to experience an INCREASE in pulse rate upon standing in response to a change
in blood pressure.
, The nurse plans to assess Donna for orthostatic vital sign changes. Which action should
the nurse take first?
- assist Donna to a standing position
- dangle Donna's feet at the bedside
- position Donna in a supine position
- elevate the head of Donna's bed - ANSWER-Position Donna to a supine position
*** orthostatic vital signs are measured in each position: lying, sitting, and standing. The
patient'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, which action should the nurse take?
-assess for auscultatory gap
-count the client's radial pulse rate
-remove the blood pressure cuff
-help the client change positions - ANSWER-Count the client's radial pulse rate.
****both the blood pressure AND pulse rate are typically measured in each position:
lying, sitting, and standing***
*the answer is NOT remove the blood pressure cuff because after the cuff is defaulted,
it is left in the same position on the same arm for all 3 BP readings
*assessment for an auscultatory gap is done WHILE the BP measurement is being
taken
In addition to obtaining Donna's vital signs, the nurse performs additional assessments.
For ongoing evaluation of Donna's fluid volume status, it is most important to obtain
which assessment data?
-urine color
-capillary refill
-body weight
-skin turgor - ANSWER-Body weight.
