NU271 HESI Case Study: Fluid Balance (week 10)

What action should the primary nurse implement?

Change the currently infusing solution to sodium chloride 0.9% Injection and change the rate to 100 mL/hour - Two errors have occurred: the wrong solution and the wrong rate of administration. These errors should both be corrected.

Which signs and symptoms of fluid volume deficit should the nurse include when educating the client and her daughter prior to discharge? (Select all that apply.)

Changes in mental status., Change in urine output., Presence of tachycardia.Longitudinal furrows on the tongue.

What is the best response by the nurse?

"This is a double-check to ensure that no errors occur." - This response provides the best client teaching. The client can participate in the plan of care more actively if explanations for interventions are provided.

What is the primary nurse's best response?

"Variance reports are used to find ways to prevent further errors." - Variance reports are used by the risk management department of healthcare agencies to look for patterns that contribute to errors so that preventive measures can be instituted.

How should the nurse document the swollen ankles and feet?

4+ pitting edema present bilateral ankles and feet. - This documentation concisely describes the degree of indentation present and its location.

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.

Which assessment is important for the nurse to perform?

Auscultate the client's breath sounds. - Fluid volume excess often causes abnormal breath sounds. Fluid collection in the lungs can impair oxygen exchange.

Which labs would the nurse expect the Healthcare Provider (HCP) to order? (Choose all that apply.)

BUN, Serum creatinine, Urine specific gravity and osmolality, Liver function panel -

Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when she changes position?

Blood pressure. - 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.

For ongoing evaluation of the client's fluid volume status, which assessment data is most important to obtain?

Body weight. - Daily weights provide the most important data about fluid volume status, so an initial weight upon admission must be obtained.

Which identifiers are acceptable for the nurse to use when verifying the right client prior to medication or treatment administration? (Select all that apply.)

Client full name., Date of birth.

Now that the client is taking oral fluids well, what action should the nurse implement?

Continue the measurement of the client's fluid intake and output. - Since the client is still receiving a significant volume of IV fluids, she remains at risk for fluid volume alterations. The nurse may initiate and maintain intake and output measurement without a prescription from the healthcare provider in most facilities.

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 blood pressure and pulse rate are typically measured in each position: lying, sitting, and standing.

Which problem often occurs in older clients and may have contributed to the fluid volume deficit the client is experiencing?

Decreased hepatic blood flow. - Decreased hepatic blood flow commonly occurs in older clients. This decreases drug metabolism, which allows drugs to remain in the body longer and produces a greater drug effect.

What action should the nurse implement?

Document the presence of inelastic skin turgor. - Skin turgor is best assessed in the older client by gently pinching a fold of skin over the sternum. Inelastic turgor is an expected finding in a client with fluid volume deficit. Additional findings may include weakness, confusion, and tachycardia.

Which items should be measured as fluid intake? (Select all that apply.)

Milk., Apple juice.

What action should the nurse take?

Notify the HCP and obtain an order for appropriate IV fluids. - Three percent sodium chloride Injection is a hypertonic solution, which will pull fluid from the interstitial and intracellular spaces into the bloodstream. It is usually prescribed for severe hyponatremia (sodium <115 mEq/L). Since the client is already experiencing a fluid volume deficit, this IV solution could worsen her condition. The nurse should obtain a prescription for an appropriate IV fluid from the healthcare provider.

What additional action should the primary nurse take?

Notify the healthcare provider of the error in treatment that occurred. - Since the prescription was not initially followed, the healthcare provider should be notified in case a change in the treatment plan is warranted.

Which action should the nurse take?

Notify the pharmacist of the error. - The pharmacist should split the medication if it does not come in the prescribed amount.

The nurse plans to assess the client for orthostatic vital sign changes. Which action will the nurse take first?

Position the client in a supine position. - Orthostatic vital signs are measured in each position: lying, sitting, and standing. The client's vital signs are first assessed in the supine position so that changes that occur when the client sits and stands can be determined.

The nurse reports to the healthcare provider her assessment and lab findings. Which laboratory result is critical and should the nurse have the HCP repeat back?

Potassium 3 mEq/L (3 mmol/L). - The client's potassium level is low and will need to be addressed by the HCP.

The nurse reports the findings to the healthcare provider and receives several prescriptions including stopping the IV fluids. Which prescription should the nurse question?

Potassium chloride 40 mEq PO. - Client's serum potassium is low. She needs potassium replacement via IV 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 healthcare provider. In addition, the patient has an order for potassium wasting diuretic.

Which action should the nurse take?

Remove the IV and restart it in a different location. - The client is experiencing phlebitis, which can lead to further complications if left untreated. Since the nurse has the responsibility to take action when IV site complications occur, the IV should be discontinued, action should be taken for the inflammation according to agency policy, and a new IV should be started at a different site.

Which lab values are most important for the nurse to monitor? (Select all that apply.)

Serum potassium (Hydrochlorothiazide, a potassium-wasting diuretic, may cause significant hypokalemia.) Magnesium. (Use of hydrochlorothiazide may also result in a decrease in serum magnesium and sodium and an increase in serum calcium and glucose.)

Which lab test will the nurse monitor to determine if this may be a factor contributing to the client's problem?

Serum protein. - Drug molecules may be distributed throughout the body bound to plasma protein molecules. A decrease in serum protein levels is an indication that there may be an increase in free, unbound drug molecules in the bloodstream.

Which intervention should the nurse take next?

Straighten the joint above the site. - Obstruction is often caused by client movement, resulting in a bend in the client's proximal joint. Therefore, this noninvasive measure should be the next action taken by the nurse.

Since the client is receiving a diuretic that contributes to the loss of potassium, the nurse must provide dietary teaching. Which foods selected by the client indicate an understanding of potassium-rich foods? (Select all that apply.)

Whole grains, Peanut butter, Tuna

The nurse will emphasize the importance of taking this medication only once a day, on what schedule?

With breakfast. - 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 adverse effects, such as nausea.