Fluid Balance- HESI Case Study Exam
Questions with correct Answers
2026/2027 A+ Graded 100% Verified
2.The nurse plans to assess the pt for orthostatic vital sign changes.
What action will the nurse take first?
Position patient in a supine position
Orthostatic vital signs are measured in three different positions: lying, sitting and
standing. So placing pt in supine position should be first
3.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
Both the BP and pulse rate are typically measured in each position lying, sitting and
standing
1. Since the client has a fluid volume deficit, the nurse anticipates a decrease in which
vital sign when Clara moves from a lying to a standing position?
Blood pressure.
Fluid volume deficit often occurs with orthostatic hypotension and tachycardia. Because
the client may experience dizziness with orthostatic hypotension the nurse should take
additional safety precautions
7.In addition to obtaining Clara's vital signs, the nurse performs additional assessments.
For ongoing evaluation of Clara's fluid volume status, it is most important to obtain
which assessment data?
Body weight
Daily weights provide the most important dataabout fluid volume status
, 6.Which labs would the nurse expect the Healthcare Provider (HCP) to order? (Choose all
that apply.)
Bun, serum creatinine, Urine spec gravity and osmolality, Liver function panel
The nurse continues to assess the client and observes that Clara's skin tents when a fold
of skin over her sternum is pinched.
What action should the nurse implement?
Document the presence of inelastic skin turgor
Skin turgor is best assessed in the elderly by gently pinching a fold of skin over the
sternum.
8.The nurse explains to the client's daughter that the client has lost approximately how
many pounds?
5
60 kg × 2.2 = 132 lbs. 137 lbs. - 132 lbs. = 5 lbs. This represents an approximate weight
loss of 5 pounds.
9.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?
Document the presence of inelastic skin tugor
Clara's daughter reports that her mother usually weighs about 150 lbs. and is 5 feet, 4
inches in height. The nurse weighs Clara and obtains a measurement of 65 kg.
The nurse explains to Clara's daughter that Clara has lost approximately how many
pounds?
7
65 kg x 2.2 = 143. 150 lbs.-143= 7lbs
The nurse then explains that Clara's weight loss represents approximately how many
liters of fluid loss?
3
7/2.2=3.2 kg
(1 kg is equivalent to 1 L)
Questions with correct Answers
2026/2027 A+ Graded 100% Verified
2.The nurse plans to assess the pt for orthostatic vital sign changes.
What action will the nurse take first?
Position patient in a supine position
Orthostatic vital signs are measured in three different positions: lying, sitting and
standing. So placing pt in supine position should be first
3.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
Both the BP and pulse rate are typically measured in each position lying, sitting and
standing
1. Since the client has a fluid volume deficit, the nurse anticipates a decrease in which
vital sign when Clara moves from a lying to a standing position?
Blood pressure.
Fluid volume deficit often occurs with orthostatic hypotension and tachycardia. Because
the client may experience dizziness with orthostatic hypotension the nurse should take
additional safety precautions
7.In addition to obtaining Clara's vital signs, the nurse performs additional assessments.
For ongoing evaluation of Clara's fluid volume status, it is most important to obtain
which assessment data?
Body weight
Daily weights provide the most important dataabout fluid volume status
, 6.Which labs would the nurse expect the Healthcare Provider (HCP) to order? (Choose all
that apply.)
Bun, serum creatinine, Urine spec gravity and osmolality, Liver function panel
The nurse continues to assess the client and observes that Clara's skin tents when a fold
of skin over her sternum is pinched.
What action should the nurse implement?
Document the presence of inelastic skin turgor
Skin turgor is best assessed in the elderly by gently pinching a fold of skin over the
sternum.
8.The nurse explains to the client's daughter that the client has lost approximately how
many pounds?
5
60 kg × 2.2 = 132 lbs. 137 lbs. - 132 lbs. = 5 lbs. This represents an approximate weight
loss of 5 pounds.
9.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?
Document the presence of inelastic skin tugor
Clara's daughter reports that her mother usually weighs about 150 lbs. and is 5 feet, 4
inches in height. The nurse weighs Clara and obtains a measurement of 65 kg.
The nurse explains to Clara's daughter that Clara has lost approximately how many
pounds?
7
65 kg x 2.2 = 143. 150 lbs.-143= 7lbs
The nurse then explains that Clara's weight loss represents approximately how many
liters of fluid loss?
3
7/2.2=3.2 kg
(1 kg is equivalent to 1 L)
