Understanding Fluid Balance: A Case Study on Hypertension and - Course Sidekick (2024)

HESI Case Study: Fluid Balance Study online at https://quizlet.com/_6u42if 1.Donna King is an 80 year old fe-male with coronary artery disease and hypertension. Her daughter brought her to the Emergency Department be- cause she has become increasingly weak and confused and was found by a neighbor wandering her neigh- borhood 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, "hy- drochlorothiazide (HydroDIURIL). Take 1 tablet daily." Donna is admitted with fluid volume deficit. Meet the Client (Title) 2.*Vital signs: Orthostatic Changes*Since Donna has fluid volume deficit,the nurse anticipates a decrease inwhich vital sign when Donna changesposition?- Respiratory rate- Blood pressure- Temperature- Pulse rate Blood pressure Rationale: Fluid volume deficit of- ten causes orthostatic hypotension and tachycardia. Because the client may experience dizziness with or- thostatic hypotension, the nurse should take additional safety pre- cautions during this assessment. 3.The nurse plans to assess Donna fororthostatic vital sign changes. Whichaction will the nurse take first? - Assist Donna to a standing position.- Position Donna in a supine position.- Elevate the head of Donna's bed.- Dangle Donna's feet at the bedside.Position Donna in a supine posi- tion. Rationale: Orthostatic vital signs are measured in each position: ly- ing, sitting, standing. The client's vi- tal signs are first assessed in the supine position so that changes that occur when the client sits and stands can be determined. 1 / 14

HESI Case Study: Fluid Balance Study online at https://quizlet.com/_6u42if 4.The nurse takes the first blood pres-sure measurement. After recording the first blood pressure measurement,what action will the nurse take?- Count the client's radial pulse rate.- Remove the blood pressure cuff. - Help the client changes position. - Assess for auscultatory gap. Count the client's radial pulse rate. Rationale: Both the blood pressure and pulse rate are typically mea- sured in each position: lying, sitting, and standing. 5.In addition to obtaining Donna's vitalsigns, the nurse performs additional assessments. Assessment (Title) 6.For ongoing evaluation of Donna's flu-id volume status, it is more important to obtain which assessment data?- Urine color.- Capillary refill.- Body weight. - Skin turgor. Body weight. Rationale: Daily weights provide the most important data about fluid volume status, so an initial weight upon admission must be obtained. 7.The nurse continues to assess theclient and observes that Donna's skin tents when a fold of skin over her ster- num is pinched. (Information) 8.What action should the nurse imple-ment?- Confirm this finding by pinching theskin on her hand.- Notify the healthcare provider thatthe client is now retaining fluid.- Advise Donna that the fluid deficitseems to be worsening.- Document the presence of inelasticskin turgor.Document the presence of inelastic skin turgor. Rationale: Skin turgor is best as- sessed in the elderly by gently pinching a fold of skin over the ster- num. Inelastic turgor is an expect- ed finding in a client with fluid vol- ume deficit. Additional findings may include weakness, confusion, and tachycardia. 2 / 14

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HESI Case Study: Fluid Balance Study online at https://quizlet.com/_6u42if 9.*Math*Donna's daughter reports that hermother usually weights 137 lbs (62.14kg) and is 5' 3" (160 cm) in height.The nurse weighs Donna and obtainsa measurement of 60 kg. The nurse explains to Donna's daugh- ter that Donna has lost approximately how many pounds? - 3. - 5. - 4. - 7. 5. Rationale: 60 kg x 2.2=132 lbs. 137 lbs.-132 lbs. = 5 lbs. This represents an approximate weight loss of 5 pounds. 10.The nurse discusses factors that con-tributed to the fluid volume deficit with Donna and her daughter. Age-related Risk Factors (Title) 11.Which problem often occurs in the el-derly and may have contributed to the fluid volume deficit Donna is experi-encing?- Decreased hepatic blood flow.- Decreased drug absorption.- Decreased drug half life- Decreased GI acidity. Decreased hepatic blood flow. Rationale: Decreased hepatic blood flow commonly occurs in the elderly. This decreases drug me- tabolism, which allows drugs to re- main in the body longer and pro- duce a greater drug effect. 12.The nurse is aware that the elderlyoften experience an increase in the amount of free, unbound drug mole- cules, which has the potential to in- crease the pharmacological effects of the drug. (Information) 13.Which lab test will the nurse monitorto determine if this may be a factor Serem protein 3 / 14