Fluid Balance Case Study

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1. 2. The nurse plans to assess Donna for B. Position Donna in a supine position.
orthostatic vital sign changes. Which action
will the nurse take first? NOTE 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
A. Assist Donna to a standing position. occur when the client sits and stands can be determined.
B. Position Donna in a supine position.
C. Elevate the head of Donna's bed.
D. Dangle Donna's feet at the bedside.
2. 3. The nurse takes the first blood pressure A. Count the client's radial pulse rate.
measurement. After recording the first
blood pressure measurement, what action NOTE Both the blood pressure and pulse rate are typically measured in each position:
will the nurse take? lying, sitting, and standing.

A. Count the client's radial pulse rate.

B. Remove the blood pressure cuff.
C. Help the client changes position.
D. Assess for auscultatory gap.
3. 16. Which problem did the nurse identify as B. Risk for injury (thrombus formation)
most pertinent in that situation?
NOTE The phlebitis at the IV site places Donna at high risk for thrombus formation.
A. Risk for impaired skin integrity. So, the nurse identified this problem, established the goal that the risk for injury will
B. Risk for injury (thrombus formation) be reduced, and implemented the interventions of removing the IV and providing care
C. Fluid volume deficit. at the site of inflammation.
D. Infection.
4. 23. The nurse reports the findings to the B. Potassium chloride 40 mEq PO.
healthcare provider and receives several
prescriptions. Which prescriptions should NOTE Donna's serum potassium is low. She needs potassium replacement via IV
the nurse question? solution instead of the PO route. A prescription for potassium chloride diluted in an
IV solution to be administered over several hours should be obtained from the HCP.
A. Furosemide (Lasix) 40 mg IV push now.
B. Potassium chloride 40 mEq PO.
C. Decrease the Normal Saline to KVO.
D. Administer oxygen per nasal cannula at 2
L/minute.
5. 25. The nurse will emphasize the importance B. With breakfast.
of taking this medication only once a day,
on what schedule? NOTE To reduce the likelihood of nocturia, the client should be instructed to take
diuretics in the morning. Additionally, taking the medication with food may reduce
A. Before eating breakfast. adverse effects, such as nausea.
B. With breakfast.
C. After lunch.
D. At bedtime.
6. 29. Which identifiers are acceptable for the nurse to use when A. Client full name.
verifying the right client prior to medication or treatment B. Date of birth.
administration? (Select all that apply) C. Current photograph.

A. Client full name.

B. Date of birth.
C. Current photograph.
D. Room number.
E. Physical location.
7. 30. The nurse is preparing discharge instructions for Donna. Which A. Changes in mental status.
signs and symptoms of fluid volume deficit should the nurse include B. Changes in urine output.
when educating the client and her daughter prior to discharge? C. Presence of tachycardia.
(Select all that apply) E. Longitudinal furrows on the tongue.

A. Changes in mental status. NOTE Cognitive impairment is associated with dehydration

B. Changes in urine output. in the older adult.
C. Presence of tachycardia. NOTE Decreased renal perfusion and altered renal
D. Tenting on arm when checking skin turgor. function can compromise the client's fluid volume status.
E. Longitudinal furrows on the tongue. NOTE Presence of tachycardia is associated with
dehydration in the older adult.
NOTE Longitudinal furrows on the tongue are indicative of
dehydration.
8. Age related Risk Factors A. Decreased hepatic blood flow.

The nurse discusses factors that contributed to the fluid volume NOTE Decreased hepatic blood flow commonly occurs in
deficit with Donna and her daughter. the elderly. This decreases drug metabolism, which allows
drugs to remain in the body longer and produce a greater
7. Which problem often occurs in the elderly and may have drug effect.
contributed to the fluid volume deficit Donna is experiencing?

A. Decreased hepatic blood flow.

B. Decreased drug absorption.
C. Decreased drug half life
D. Decreased GI acidity.
9. Assessment C. Body weight.

In addition to obtaining Donna's vital signs, the nurse performs Note Daily weights provide the most important data about
additional assessments. fluid volume status, so an initial weight upon admission
must be obtained.
4. For ongoing evaluation of Donna's fluid volume status, it is more
important to obtain which assessment data?

A. Urine color.
B. Capillary refill.
C. Body weight.
D. Skin turgor.
10. Before Donna's discharge, the nurse provides client teaching related to the prescribed A. Baked potato (844 mg
hydrochlorothiazide (HydroDIURIL). K).
C. Chicken breast (458 mg
26. Since Donna is receiving a diuretic that contributes to the loss of potassium, the nurse must K).
provide dietary teaching. Which foods selected by the client indicate an understanding of E. Grapefruit juice (378 mg
potassium rich foods? K).

A. Baked potato.
B. Green beans.
C. Chicken breast.
D. Apple.
E. Grapefruit juice.
11. Case Outcome ...

Donna's fluid balance is restored. She is taking oral fluids well, her IV solution has been
discontinued, and she has received client teaching about fluid balance and the correct
administration of her diuretic. The nurse observes that Donna is able to break the scored medication
tablet without difficulty. Donna is discharged home, accompanied by her daughter.
12. Donna has abnormal breath sounds, bilateral pitting edema, and jugular vein distention. A. Increase in rate and
volume.
21. Which change in Donna's pulse will the nurse anticipate?
NOTE As fluid volume
A. Increase in rate and volume. increases to the point of
B. Decrease in rate and volume. fluid volume excess, the
C. Increase in rate, but no change in the volume. client will develop
D. Decrease in rate, but no change in the volume. tachycardia (increase in
rate) and a bounding pulse
(increase in volume).
13. 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.
14. Fluid Volume Excess A. Auscultate the client's
breath sounds.
Donna's intake and output measurements indicate her intake is greater than her output. The nurse is
concerned that Donna may develop fluid volume excess. NOTE Fluid volume
excess often causes
19. Which assessment is important for the nurse to perform? abnormal breath sounds.
Fluid collection in the
A. Auscultate the client's breath sounds. lungs can impair oxygen
B. Measure the client's tympanic temperature. exchange and result in
C. Compare the client's muscle strength bilaterally. hypoxemia.
D. Ask the client if she is experiencing any syncope.
15. Further findings include oxygen saturation level of 90%, seem sodium of 140 D. Potassium 3.
mEq/L, serum chloride 105 mmil/L, albumin 4 g/dL, AST 30 IU/L, and serum
potassium of 3 mEq/L. NOTE The client's potassium level is low and
will need to be addressed by the HCP.
22. The nurse reviews the client's laboratory results. Which laboratory result is
critical and should be reported to the HCP.

A. Sodium 140.
B. Chloride 105.
C. Albumin 4.
D. Potassium 3.
16. Intake and Output Measurement D. Milk.
E. Apple juice.
Donna continues to receive 0.9% Normal Saline at a rate of 100 ml/hour. She is
stronger and has started taking oral food and fluids well. She receives a regular NOTE Oral fluid intake includes only foods that
no added salt diet. Her breakfast includes one cup of scrambled eggs, one are liquid at room temperature.
bowl of oatmeal, a fresh orange, apple juice, and a carton of milk.

17. Which items should be measured as fluid intake?

A. Scrambled egge
B. Bowl of oatmeal
C. Fresh orange.
D. Milk.
E. Apple juice.
17. Intravenous Fluids D. Obtain appropriate IV fluid prescription.

The nurse starts an intravenous line to administer fluids. The prescription states, NOTE Three percent saline is a hypertonic
"3% Normal Saline to infuse at 100 ml/hour." The client's most recent seem solution, which will pull fluid from the intestinal
sodium level is 135 mEq/L. and intracellular spaces into the bloodstream. It
is usually prescribed for severe hyponatremia.
9. What action should the nurse take?

A. Hang 0.9% Normal Saline at 100 ml/hour.

B. Begin infusing the solution at a keep open rate.
C. Start the intravenous solution as prescribed.
D. Obtain appropriate IV fluid prescription.
18. Legal Considerations: Treatment Error B. Notify the healthcare provider of the error in
treatment that occurred
After hanging the correct IV solution at the correct rate of infusion, the nurse
discusses the error with the nurse who hung the first IV solution. Together, the NOTE Since the prescription was not initially
nurses complete a variance (incident ) report. followed, the healthcare provider should be
notified in case a change in the treatment plan
11. What additional action should the primary nurse take? is warranted.

A. Discuss the consequences of the error with the hospital legal counsel.
B. Notify the healthcare provider of the error in treatment that occurred
C. Report to the hospital pharmacist that a variance report was written.
D. Notify the hospital educator of the need for staff training about IV fluids.
19. Local IV Site Complications C. Straighten the joint above the site.

Later that day, Donna's IV pump alarm sounds. The nurse notes NOTE Obstruction is often caused by client movement,
that the IV is not infusing in the right antecubital area, and the resulting in a bend in the client's proximal joint. Therefore, this
alarm indicates an obstruction is present. The nurse determines noninvasive measure should be the next action taken by the
that all the clamps are open and there are no kinks in the tubing. nurse.

13. Which intervention should the nurse take next?

A. Apply light pressure about the site.

B. Lower the IV solution below the site.
C. Straighten the joint above the site.
D. Change the IV site dressing.
20. Math B. 5.

Donna's daughter reports that her mother usually weights 137 lbs NOTE 60 kg x 2.2=132 lbs. 137 lbs.-132 lbs. = 5 lbs. This
(62.14 kg) and is 5' 3" (160 cm) in height. The nurse weighs Donna represents an approximate weight loss of 5 pounds.
and obtains a measurement of 60 kg.

6. The nurse explains to Donna's daughter that Donna has lost

approximately how many pounds?

A. 3.
B. 5.
C. 4.
D. 7.
21. Medication Administration: Oral Tablets A. Observe the tablet to see if it is scored.

In preparing to administer the hydrochlorothiazide, the nurse NOTE A scored tablet can safely be divided so that the client
notes that the prescribed dose is 12.5 mg, and the tablet may receive the prescribed dose. Hydrochlorothiazide is a
available is 25 mg. scored tablet, and 25 mg is the lowest tablet strength
available. The nurse should therefore assess Donna's ability to
27. Which actin should the nurse take? break the tablet.

A. Observe the tablet to see if it is scored.

B. Notify the pharmacist of the error.
C. Hold the medication until the right does is available.
D. Document the change in dose on the medication record.
22. Medication Errors D. Change the currently infusing solution to 0.9%
Normal Saline and change the rate to 100 ml/hour.
A short while later, a prescription for 0.9% Normal Saline at 100 ml/hour
is received. Donna's primary nurse is at lunch, so another nurse hangs NOTE Two errors have occurred: the wrong solution
the solution. When checking Donna upon returning from lunch, the and wrong rate of administration. These error should
primary nurse observes that a solution of 5% Dextrose and 0.9% Normal both be corrected.
Saline is infusing at 125 ml/hour.

10. What action should the primary nurse implement?

A. Obtain a container of 0.9% Normal Saline to hang when the present

solution has finished infusing.
B. Decrease the infusion rate of the present solution to 75 ml/hour to
compensate for the error made.
C. Stop the IV solution currently infusing and monitor the client for
signs of an anaphylactic reaction.
D. Change the currently infusing solution to 0.9% Normal Saline and
change the rate to 100 ml/hour.
23. The nurse also observes that Donna's feet and ankles are swollen. When B. 4+ pitting edema present around ankles and feet.
the nurse presses a finger over the client's ankle (boney prominence),
an 8 mm indentation appears. NOTE This documentation concisely describes the
degree of indentation present and its location.
20. How will the nurse document this finding?

A. Gross edema in the lower extremities.

B. 4+ pitting edema present around ankles and feet.
C. Stage 1 pressure ulcer forming due to ankle edema.
D. Blanching and induration present bilaterally.
24. The nurse continues to assess the client and observes that Donna's skin D. Document the presence of inelastic skin turgor.
tents when a fold of skin over her sternum is pinched.
NOTE Skin turgor is best assessed in the elderly by
5. What action should the nurse implement? gently pinching a fold of skin over the sternum.
Inelastic turgor is an expected finding in a client with
A. Confirm this finding by pinching the skin on her hand. fluid volume deficit. Additional findings may include
B. Notify the healthcare provider that the client is now retaining fluid. weakness, confusion, and tachycardia.
C. Advise Donna that the fluid deficit seems to be worsening.
D. Document the presence of inelastic skin turgor.
25. The nurse is aware that the elderly often experience an increase in the B. Serem protein
amount of free, unbound drug molecules, which has the potential to
increase the pharmacological effects of the drug. NOTE Drug molecules may be distributed through the
body bound to plasma protein molecules. A decrease
8. Which lab test will the nurse monitor to determine if this may be a in serum protein levels is an indication that there may
factor contributing to Donna's problem? be in an increase in free, unbound drug molecules in
the bloodstream.
A. Serem creatinine
B. Serem protein
C. AST.
D. BUN.
26. The nurse resolves the obstruction, and the IV B. Remove the IV and restart it in a different location.
solution begins to infuse. The next day the nurse
observes that the IV insertion site is inflamed and NOTE The client is experiencing phlebitis, which can lead to further
tender. The label on the IV site indicates the current complications if left untreated. Since the nurse has the responsibility to take
IV has been in place for 36 hours. action when IV site complications occur, the IV should be discontinued,
action should be taken for the inflammation according to agency policy,
14. Which action should the nurse take? and a new IV should be started at a different site.

A. Continue the IV with the arm elevated on a pillow.

B. Remove the IV and restart it in a different
location.
C. Notify the healthcare provider that the IV site
appears inflamed.
D. Complete a variance report regarding the IV site.
27. The nurse who made the errors is very upset about D. "Variance reports are used to find ways to prevent further errors."
writing a variance (incident ) report and states, "I've
never made an error before. What if I get fired?" NOTE Variance reports are used by the risk management department of
healthcare agencies to look for patterns that contribute to errors so that
12. How should the primary nurse respond? preventative measures can be instituted.

A. "The variance report will show that this is your first

medication error. "
B. "As long as you understand the error, we can
disregard this report."
C. "Since no harm was done to the client, the
variance report will not matter."
D. "Variance reports are used to find ways to
prevent further errors."
28. Nursing Process A. Analyze the data.

The nurse used the nursing process in deciding to NOTE The nurse analyzes the assessment data to determine if
remove Donna's IV and restart it in a new location. characteristics occur that define a problem. A problem is then stated, a
goal established, and the interventions are planned and implemented.
15. When assessing the IV site, what step of the
nursing process did the nurse use?

A. Analyze the data.

B. Plan interventions.
C. Determine the problem.
D. Establish a goal.
29. Pharmacology: Diuretics C. Serem potassium.
E. Magnesium.
Donna's fluid volume excess improves and the
prescription for hydrochlorothiazide (HydroDIURIL) NOTE Hydrochlorothiazide (HydroDIURIL), a potassium wasting diuretic,
12.5 mg PO daily is restarted. may cause significant hypokalemia.
NOTE Use of hydrochlorothiazide (HydroDIURIL) may also result in a
24. Which lab values are most important for the nurse decrease in serum magnesium and sodium and an increase in serum
to monitor? calcium and glucose.
(Select all that apply)

A. Hemoglobin.
B. White blood cell count.
C. Serem potassium.
D. Prothrombin Time (PT/INR)
E. Magnesium.
30. Upon entering Donna's room with the medication, the D. "This is a double check to ensure that no errors occur."
nurse checks Donna's ID band. Donna states, "You take
care of me every day. Why do you keep looking at my NOTE This response provides the best client teaching. The client can
ID? participate in the plan of care more actively if explanations for
interventions are provided.
28. What is the best response by the nurse?

A. "It is hospital policy to always check client ID.

B. "Your HCP has asked that we always perform this
check."
C. "Wearing an ID band is important for all clients."
D. "This is a double check to ensure that no errors
occur."
31. Vital signs: Orthostatic Changes B. Blood pressure

1. Since Donna has fluid volume deficit, the nurse Note Fluid volume deficit often causes orthostatic hypotension and
anticipates a decrease in which vital sign when Donna tachycardia. Because the client may experience dizziness with orthostatic
changes position? hypotension, the nurse should take additional safety precautions during
this assessment.
A. Respiratory rate
B. Blood pressure
C. Temperature
D. Pulse rate
32. When Donna was first admitted, the HCP did not include B. Continue the measurement of the client's fluid intake and output.
intake and output measurement in the initial
prescriptions, but the primary nurse initiated this NOTE Since Donna is still receiving a significant volume of IV fluids,
assessment activity. she remains at risk for fluid volume alterations. The nurse may initiate
and maintain intake and output measurement without a prescription from
18. Now that Donna is taking oral fluids well, what action the HCP.
should the nurse implement?

A. Notify the healthcare provider that a prescription to

continue intake and output measurement is needed.
B. Continue the measurement of the client's fluid intake
and output.
C. Stop measuring the client's fluid intake and output as
long as she takes oral fluids.
D. Measure the client's fluid output, but discontinue
measuring fluid intake.