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Grand Canyon University NRS 201: Fluid Balance Case Study Answers., Assignments of Nursing

Grand Canyon University (GCU)Nursing

Fluid Balance Case Study 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.

Typology: Assignments

2024/2025

Available from 07/05/2025

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Fluid Balance Case Study
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.
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
2. The nurse plans to assess the client for orthostatic vital signs 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 client’s feet at the bedside
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
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.
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
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.
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Download Grand Canyon University NRS 201: Fluid Balance Case Study Answers. and more Assignments Nursing in PDF only on Docsity!

Fluid Balance Case Study

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. 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
  2. The nurse plans to assess the client for orthostatic vital signs 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 client’s feet at the bedside
  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 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.
  4. 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 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.
  1. 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
  2. Which labs would the nurse expect the Healthcare Provider (HCP) to order? (Select all that apply). a. BUN b. Serum creatinine c. Urine specific gravity and osmolality d. Liver function panel e. None of the above Assessment In addition to obtaining the client’s vital signs, the nurse performs additional assessments.
  3. 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 Math – 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.
  4. 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 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.
  5. 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

Local IV Site Complications Later that day, the client’s IV pump alarms 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.

  1. Which intervention should the nurse take next? a. Apply light pressure above the site b. Lower the IV solution below the site c. Straighten the joint above the site d. Change the IV dressing 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 arm 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 Intake and Output Measurements 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, apple juice, and a carton of milk.
  3. 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
  4. 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 fluid 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 Fluid Volume Excess The nurse is concerned that the client may develop fluid volume 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 The client has abnormal breath sounds, bilaterally 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 Further finding include oxygen saturation level of 90%, serum sodium of 140 mEq/L, serum chloride 105 mEq/L, albumin 4 g/dL, AST 30 U/L and serum potassium of 3 MEq/L from daily labs.
  3. The nurse reports to the healthcare provider her assessment and lab findings. Which laboratory results is critical and should the nurse have the HCP repeat back? a. Sodium 140 mEq/L b. Chloride 105 mEq/L c. Magnesium 2 mg/dL d. Potassium 3 mEq/L

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 the 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. Changes in mental status b. Change in urine output c. Presence of tachycardia d. Tenting on the arm when checking skin turgor e. Longitudinal furrows on the tongue.
  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
  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 Case Outcome The client’s fluid balance is restored. She is taking oral fluids well, her IV solution has been discontinued, and she has received client teaching about fluid balance and the correct administration of her diuretic and verbalizes understanding. The nurse observes the client re-demonstration how to break the scored medication tablet and she does so without difficulty, if needed. The client is discharged home, accompanied by her daughter.