Fluid Balance- HESI case study
The nurse plans to assess Clara for orthostatic vital sign changes. What action will the nurse take first?
Position Clara in a supine position
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
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?
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?
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
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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?
The nurse then explains that Clara’s weight loss represents approximately how many liters of fluid loss?
For each 1 kg of body weight lost/gained is equivalent to 1 L of fluid)
The nurse discusses factors that contributed to Clara’s fluid volume deficit with Clara and her daughter. Which problem often occurs in the elderly and may have contributed to the fluid volume deficit Clara is experiencing?
Decreased hepatic blood flow
The nurse is aware that the elderly 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 Clara’s problem?
The nurse starts an intravenous line to administer fluids. The prescription states, “3% Normal Saline to infuse at 100 ml/hour.” The client’s most recent serum sodium level is 135 mEq/L. What action should the nurse take?
Consult with the healthcare provider about the prescription. (Normal Sodium levels 136-145 mEq/L; 3% sodium chloride has a hypertonic concentration; normal saline is 0.9% sodium chloride)
A short while later, a prescription for 0.9% Normal Saline at 100 ml/hour is received. Clara’s primary nurse is at lunch, so another nurse hangs the solution. When checking Clara upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose and 0.9% Normal Saline is infusing at 125 ml/hour. What action should the primary nurse implement?
Change the currently infusing solution to 0.9% Normal Saline and change the rate to 100 ml/hour.
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 nurses complete a variance (incident) report. What additional action should the primary nurse take?
Notify the healthcare provider of the error in treatment that occurred.
The nurse who made the errors is very upset about writing a variance (incident) report and states, “I’ve never made an error before. What if I get fired?” How should the primary nurse respond?
“Variance reports are used to find ways to prevent further errors.”
Later that day, Clara’s IV pump alarm sounds. The nurse notes that the IV is not infusing in the right antecubital area, and the alarm indicates an obstruction is present. The nurse determines that all the clamps are open and there are no kinks in the tubing. What intervention should the nurse take next?
Straighten the joint above the site.
The nurse resolves the obstruction, and the IV solution begins to infuse. The next day the nurse observes that the IV insertion site is inflamed and tender. The label on the IV site indicates the current IV has been in place for 36 hours. What action should the nurse take?
Remove the IV and restart it in a different location.
The nurse used the nursing process in deciding to remove Clara’s IV and restart it in a new location. When assessing the IV site, what step of the nursing process did the nurse use?
Analyze the data
Which problem did the nurse identify as most pertinent in that situation?
Risk for injury (thrombus formation).
Clara 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 no-added-salt diet. Her breakfast includes one cup of scrambled eggs, one bowl of oatmeal, a fresh orange, and a carton of milk. In addition to the milk, which item should be measured as fluid intake?
Only the milk
Oral fluid intake includes only foods that are liquid at room temperature. When Clara was first admitted, the healthcare provider did not include intake and output measurement in the initial prescriptions, but the primary nurse initiated this assessment activity.
Continue the measurement of the client’s fluid intake and output
Clara’s intake and output measurements indicate her intake is greater than her output. The nurse is concerned that Clara may develop fluid volume excess. Which assessment is important for the nurse to perform?
Auscultate the client’s breath sounds
The nurse also observes that Clara’s feet and ankles are swollen. When the nurse presses a finger over the client’s ankle (bony prominence), a 4 mm indentation appears. How will the nurse document this finding?
2+ pitting edema present around ankles and feet.
Clara has abnormal breath sounds, bilateral pitting edema, and jugular vein distention. Which change in Clara’s pulse will the nurse anticipate?
Increase in rate and volume
Further findings include oxygen saturation level of 90%, serum sodium of 140 mEq/L, and serum potassium of 3 mEq/L. The nurse reports the findings to the healthcare provider and receives several prescriptions.Which prescription should the nurse question?
Potassium chloride 40 mEq IV push now.
It is important for the nurse to monitor what lab value
Before Clara’s discharge, the nurse provides client teaching related to the prescribed hydrochlorothiazide (HydroDIURIL). Clara’s fluid volume excess improves and the prescription for hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted. The nurse will emphasize the importance of taking this medication only once a day, on what schedule?
Since Clara is receiving a diuretic that contributes to the loss of potassium, the nurse must provide dietary teaching. Which food(s) selected by the client indicate an understanding of potassium-rich foods? (Select all that apply.)
baked potato. chicken breast and grapefruit
In preparing to administer the hydrochlorothiazide, the nurse notes that the prescribed dose is 12.5 mg, and the tablet available is 25 mg. What action should the nurse take?
Observe the tablet to see if it is scored.
Upon entering Clara’s room with the medication, the nurse checks Clara’s identification band. Clara states, “You take care of me every day. Why do you keep looking at my identification?” What is the best response by the nurse?
“This is a double-check to ensure that no errors occur.”