Fluid Balance - HESI RN - Evolve

Page 7 Fluid Volume Excess The nurse is concerned that the client may develop fluid excess because the client's intake is greater than her output and both ankles and feet are swollen. 1. Which assessment is important for the nurse to perform? A. Auscultate the client's breath sounds. B. Measure the client's tympanic temperature. C. Compare the client's muscle strength bilaterally. D. Ask the client if she is experiencing any syncope.

A. Auscultate the client's breath sounds.

3. Which labs would the nurse expect the Healthcare Provider (HCP) to order? (Choose all that apply) A. BUN B. Serum creatinine C. Urine specific gravity and osmolality D. Liver function panel E. None of the above

A. BUN B. Serum creatinine C. Urine specific gravity and osmolality D. Liver function panel

Page 10 The client's fluid volume excess improves and the prescription for hydrochlorothiazide 12.5 mg PO daily is restarted. The client is ready to be discharged, the nurse provides client teaching related to the prescribed hydrochlorothiazide. 1. 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) A. Change in mental status. B. Change in urine output. C. Presence of tachycardia. D. Tenting on arm when checking skin turgor. E. Longitudinal furrows on the tongue.

A. Change in mental status. B. Change in urine output. C. Presence of tachycardia. E. Longitudinal furrows on the tongue.

2. Which identifiers are acceptable for the nurse to use when verifying the right client prior to medication or treatment administration? (Select all that apply) A. Client full name. B. Date of birth. C. Current photograph. D. Room number. E. Physical location.

A. Client full name. B. Date of birth.

3. The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take? A. Count the client's radial pulse rate. B. Remove the blood pressure cuff. C. Help the client change positions. D. Assess for an auscultatory gap.

A. Count the client's radial pulse.

Page 2 Age-related Risk Factors The nurse discusses factors that contributed to the client's fluid volume deficit with her daughter, and receives orders for labs to be obtained. 1. Which problem often occurs in older client's and may have contributed to the fluid volume deficit the client is experiencing? A. Decreased hepatic blood flow. B. Decreased drug absorption. C. Decreased drug half-life. D. Decreased GI acidity.

A. Decreased hepatic blood flow.

3. 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) A. Whole grains. B. Canned green beans. C. Peanut Butter. D. Apple. E. Tuna.

A. Whole grains. C. Peanut Butter.

The client has abnormal breath sounds, bilateral pitting edema, and jugular vein distention. 2. How should the nurse document the swollen ankles and feet? A. Gross edema in the lower extremities. B. 4+ pitting edema present bilateral ankles and feet. C. Stage 1 pressure ulcer forming due to ankle edema. D. Blanching and induration present bilaterally.

B. 4+ pitting edema present bilateral ankles and feet.

The client's daughter reports that her mother usually weighs about 137 lbs. and is 5 feet, 3 inches in height. The nurse weighs the client and obtains a measurement of 60 kg. 2. The nurse explains to the client's daughter that the client has lost approximately how many pounds? A. 3 B. 5 C. 4 D. 7

B. 5

Page 1 Vital Signs: Orthostatic Changes 1. Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when she changes position? A. Respiratory Rate B. Blood Pressure. C. Temperature. D. Pulse Rate

B. Blood Pressure

2. Now that the client is taking oral fluids well, what action 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 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.

B. Continue the measurement of the client's intake and output.

Legal Consideration: Treatment Error After hanging the correct IV solution at the correct rate of infusion, the primary nurse discusses the error with the nurse who hung the first IV solution. Together, the nurses complete a variance (incident) report. 3. What action should the primary nurse take? A. Discuss the consequences of the error 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.

B. Notify the healthcare provider of the error in treatment that occurred.

Page 9 Medication Administration: The HCP prescribes hydrochlorothiazide (HCTZ) 12.5 mg PO daily. In preparing to administer the HCTZ, the nurse notes that the prescribed dose is 12.5 mg, and the tablet that arrives from the pharmacy is 25 mg. 1. What action should the nurse take? A. Obtain a pill splitter and split the medication in half. B. Notify the pharmacy of the error. C. Administer the 25 mg dose until the right dose is available. D. Document the change in dose on the medical record.

B. Notify the pharmacy of the error.

2. The nurse plans to assess the client for orthostatic vital sign changes. Which action will the nurse take first? A. Assist the client to a standing position. B. Position the client in a supine position. C. Elevate the head of the client's bed. D. Dangle the clients feet at the bedside.

B. Position the client in a supine position.

2. The nurse reports the findings to the healthcare provider and receives several prescriptions including stopping the IV fluids. Which prescription should the nurse question? A. Furosemide 40 mg IV push now. B. Potassium chloride 40 mEq PO. C. Decrease the sodium chloride injection to KVO. D. Administer oxygen per nasal cannula at 2 L/minute.

B. Potassium chloride 40 mEq PO.

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. 2. Which action should the nurse take? A. Continue the IV with the alarm 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 an occurrence report regarding the IV site.

B. Remove the IV and restart it in a different location.

The nurse is aware that older clients often experience an increased in the amount of free, unbound drug molecules, which has the potential to increase the pharmacological effects of the drug. 2. Which lab test will the nurse monitor to determine if this may be a factor contributing to the client's problem? A. Serum creatinine. B. Serum protein. C. AST. D. BUN.

B. Serum Protein.

2. The nurse will emphasize the importance of taking this medication only once a day, on what schedule? A. Before eating breakfast. B. With breakfast. C. After lunch. D. At bedtime.

B. With breakfast.

Page 3 Assessment In addition to obtaining the client's vital signs, the nurse performs additional assessments. 1. For ongoing evaluation of the client's fluid volume status, which assessment data is most important to obtain? A. Urine color. B. Capillary refill. C. Body weight. D. Skin turgor.

C. Body weight.

Pharmacology: Duretics The client's fluid volume excess improves and the prescription for hydrochlorothiazide 12.5 mg PO daily is restarted. 3. Which lab values are most important for the nurse to monitor? (Select all that apply) A. Hemoglobin B. White blood cell count C. Serum potassium D. Prothrombin Time (PT/INR) E. Magnesium

C. Serum potassium E. Magnesium

Page 5 Local IV Site Complications Later that day, the client'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 clamps are open and there are no kinks in the tubing. 1. What intervention should the nurse take next? A. Apply light pressure to the site. B. Lower the IV solution below the site. C. Straighten the joint above the site. D. Change the IV site dressing.

C. Straighten the joint above the site.

The nurse continues to assess the client and observes that the client's skin tents when a fold of skin over her sternum is pinched. 3. What action should the nurse implement? A. Confirm this finding by pinching the skin on her hand. B. Notify the healthcare provider that the client is now retaining fluid. C. Advise the client that the fluid deficit seems to be worsening. D. Document the presence of inelastic skin turgor.

D. Document the presence of inelastic skin turgor.

Upon entering the client's room with the mediation, the nurse checks the client's identification band. The client states, "You take care of me ever day. Why do you keep looking at my identification?" 3. What is the best response by the nurse? A. "It is hospital policy to always check client identification." B. " Your healthcare provider has asked that we always perform this check." C. "Wearing an identification band is important for all clients." D. "This is a double-check to ensure that no errors occur."

D. "This is a double-check to ensure that no errors occur."

The nurse who made the errors is very upset about writing an occurrence report and states, "I've never made an error before. What if I get fired?" 4. What is the primary nurse's best response? A. "The occurrence report will show that this is your first medication error." B. "As long as you understand your error, we can disregard this report." C. "Since no harm was done to the client, the occurrence report will not matter." D. "Variance reports are used to find ways to prevent further errors."

D. "Variance reports are used to find ways to prevent further errors."

A short while late, a prescription for sodium chloride 0.9% injection IV at 100 mL/hour is received and daily labs including Liver Function Panel (LFP), Complete Metabolic Panel (CMP), Blood Urea Nitrogen (BUN), and Creatinine. The client's primary nurse is at lunch, so another nurse hangs the solution. When checking the client, upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose and sodium chloride 0.9% injection is infusing at 125 mL/hour. 2. What action should the primary nurse implement? A. Obtain a container of sodium chloride 0.9% injection to hand 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 sodium chloride 0.9% injection and change the rate to 100 mL/hour.

D. Change the currently infusing solution to sodium chloride 0.9% injection and change the rate to 100 mL/hour.

Page 6 Intake and Output Measurement The client continues to receive sodium chloride 0.9 injection 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. 1. Which items should be measured as fluid intake? (Select all that apply.) A. Scrambled eggs. B. Bowl of oatmeal. C. Fresh orange. D. Milk. E. Apple juice.

D. Milk. E. Apple juice.

Page 4 The nurse starts an intravenous line to administer fluids. The prescription states "3% sodium chloride injection to infuse at 100 mL/hour." The client's most recent serum sodium level is 135 mEq/L (135 mmol/L). 1. What action should the nurse take? A. Hang sodium chloride 0.9% injection at 100 mL/hour. B. Begin infusing 3% sodium chloride injection at keep-vein-open rate. C. Start the 3% sodium chloride injection as prescribed. D. Notify the HCP and obtain an order for appropriate IV fluids.

D. Notify the HCP and obtain an order for appropriate IV fluids.

Page 8 Further findings include oxygen saturation level of 90%, serum sodium of 140 mEq,L (140 mmol/L), serum chloride 105 mEq/L (105 mmol/L), albumin 4g/dL (40 g/L), AST 30 U/L (0.50 mckat/L), and serum potassium of 3 mEq/L (3 mmol/L) from daily labs. 1. The nurse reports to the healthcare provider her assessment and lab findings. Which laboratory result is critical and should have the nurse have the HCP repeat back? A. Sodium of 140 mEq,L (140 mmol/L) B. Chloride 105 mEq/L (105 mmol/L) C. Magnesium 2 mg/dL (0.82 mmol/L) D. Potassium of 3 mEq/L (3 mmol/L)

D. Potassium of 3 mEq/L (3 mmol/L)