HESI Fluid Balance Flashcards
Scenario: An older adult with coronary artery disease and hypertension was brought to the Emergency Department by her daughter because she has become increasingly weak and confused. The client was found by a neighbor wandering her neighborhood unable to locate her home. The client’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. Take 1 tablet daily.” The client is admitted with fluid volume deficit.
Since the client has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when she changes position?
Blood pressure
Rationale: 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.
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.
Rationale: 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 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.
Rationale: Both the blood pressure and pulse rate are typically measured in each position: lying, sitting, and standing.
Age-Related Risk Factors: THe nurse discusses factors that contributed to the client’s fluid volume deficit with her and her daughter, and receives orders for labs to be obtained.
Which problem occurs in older client’s and may have contributed to the fluid volume deficit the client is experiencing?
Decreased hepatic blood flow.
Rationale: 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.
The nurse is aware that older clients 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 the client’s problem?
Serum protein
Rationale: 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 labs would the nurse expect the Healthcare Provider (HCP) to order?
BUN: Increased level could indicate renal disease or dehydration.
Serum creatinine: Increase indicates renal disease.
Urine specific gravity and osmolality: dehydration, reduced renal blood flow, and increase in ADH secretion elevate specific gravity. Overhydration, early renal disease, and inadequate ADH secretion reduce specific gravity.
Liver function panel: If a decrease in liver function occurs such as with aging or liver disease, a medication is usually eliminated more slowly, resulting in its accumulation. Patients are at risk for medication toxicity if organs that metabolize medications are not functioning correctly.
In additional to obtaining the client’s vital signs, the nurse performs additional assessments.
For ongoing evaluation of the client’s fluid volume status, which assessment data is most important to obtain?
Body weight
Rationale: Daily weights provide the most important data about fluid volume status, so an initial weight upon admission must be obtained.
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.
The nurse explains to the client’s daughter that the client has lost approximately how many pounds.
5
Rationale: 60 kg x 2.2 = 137 ibs. - 132 lbs. = 5 pounds. This represents an approximate weight loss of 5 pounds.
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.
What action should the nurse implement?
Document the presence of inelastic skin turgor.
Rationale: 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 a fluid volume deficit. Additional findings may include weakness, confusion, and tachycardia.
The nurse starts an IV 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).
What action should the nurse take?
Notify the HCP and obtain an order for appropriate IV fluids.
Rationale: 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).
A short while later, a prescription for sodium chloride 0.9% injection IV at 100mL/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.
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.
Rationale: Two errors have occurred: the wrong solution and the wrong rate of administration. These errors should both be corrected.
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.
What additional action should the primary nurse take?
Notify the healthcare provider of the error in treatment that occurred.
Rationale: Since the prescription was not initially followed, the healthcare provider should be notified incase a charge in the treatment plan is warranted.
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?”
What is the primary nurse’s best response?
Variance reports are used to find ways to prevent further errors.
Rationale: Variance reports are used by the risk management department of healthcare agencies to look for patterns that contribute to errors so that preventative measures can be instituted.
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 the clamps are open and there are no kinks in the tubing.
Which intervention should the nurse take next?
Straighten the joint above the site.
Rationale: 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.
