NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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Vital signs: Orthostatic Changes
The nurse plans to assess Clara for orthostatic vital sign changes.
Since Clara has a fluid volume deficit, the nurse anticipates a decrease in which
vital sign when Clara moves from a lying to a standing position?
A) Respiratory
rate.
INCORRECT
Respiratory rate is unlikely to be affected by a change in position.
B) Blood
pressure.
CORRECT
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.
C) Temperat
ure.
INCORRECT
Temperature is unlikely to be affected by a change in position.
D) Pulse
rate.
INCORREC
NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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,NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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T
The client's pulse rate is likely to increase upon standing in response to a change in
another vital sign.
Assessment
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?
A) Urine
color.
INCORREC
T
This provides valuable assessment data related to fluid volume, but it is not the
most important data for ongoing evaluation of fluid volume.
B) Capillary
refill.
INCORRECT
NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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,NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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This provides valuable assessment data regarding adequacy of tissue perfusion,
which may be impacted by fluid volume, but it is not the most important
assessment related to fluid volume.
C) Body
weight.
CORRECT
NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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, NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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Daily weights provide the most important data about fluid volume status, so an
initial weight upon admission must be obtained.
D) Skin
turgor.
INCORREC
T
This provides valuable assessment data related to fluid volume, but it is not the
most important data for ongoing evaluation of fluid volume.
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?
A) Confirm this finding by pinching the skin
on her hand. INCORRECT
The elderly frequently experience inelastic skin turgor of the hands, so this is not a
valuable indicator of fluid volume status.
NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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GUARANTEED SUCCESS RATED A+ LATEST UPDATE 2022
Vital signs: Orthostatic Changes
The nurse plans to assess Clara for orthostatic vital sign changes.
Since Clara has a fluid volume deficit, the nurse anticipates a decrease in which
vital sign when Clara moves from a lying to a standing position?
A) Respiratory
rate.
INCORRECT
Respiratory rate is unlikely to be affected by a change in position.
B) Blood
pressure.
CORRECT
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.
C) Temperat
ure.
INCORRECT
Temperature is unlikely to be affected by a change in position.
D) Pulse
rate.
INCORREC
NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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,NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
GUARANTEED SUCCESS RATED A+ LATEST UPDATE 2022
T
The client's pulse rate is likely to increase upon standing in response to a change in
another vital sign.
Assessment
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?
A) Urine
color.
INCORREC
T
This provides valuable assessment data related to fluid volume, but it is not the
most important data for ongoing evaluation of fluid volume.
B) Capillary
refill.
INCORRECT
NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
GUARANTEED SUCCESS RATED A+ LATEST UPDATE 2022
,NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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This provides valuable assessment data regarding adequacy of tissue perfusion,
which may be impacted by fluid volume, but it is not the most important
assessment related to fluid volume.
C) Body
weight.
CORRECT
NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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, NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
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Daily weights provide the most important data about fluid volume status, so an
initial weight upon admission must be obtained.
D) Skin
turgor.
INCORREC
T
This provides valuable assessment data related to fluid volume, but it is not the
most important data for ongoing evaluation of fluid volume.
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?
A) Confirm this finding by pinching the skin
on her hand. INCORRECT
The elderly frequently experience inelastic skin turgor of the hands, so this is not a
valuable indicator of fluid volume status.
NUR 324 FUNDAMENTALS HESI EXAM QUESTIONS AND ANSWERS 100%
GUARANTEED SUCCESS RATED A+ LATEST UPDATE 2022
