Fluid Balance

Fluid Balance Meet the Client Meet the Client: Donna King, Donna King is an 80-year-old female with coronary artery disease and hypertension. Her daughter brought her to the Emergency Department because she has become increasingly weak and confused and was found by a neighbor wandering her neighborhood 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, "hydrochlorothiazide (HydroDIURIL). Take 1 tablet daily." Donna is admitted with fluid volume deficit. Important to Know 1. Your first answer is the one that counts towards your score, but you’ll be prompted to try again if you get the wrong answer. When you get the right answer, you’ll go to the next section. 2. If you choose to re-take a Case Study, you will no longer be able to see your previous score. Section 1 Vital signs: Orthostatic Changes Question 1 of 30 Since Donna has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Donna changes position? Respiratory rate. Respiratory rate is unlikely to be affected by a change in 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. Temperature. Temperature is unlikely to be affected by a change in position. Pulse rate. The client's pulse rate is likely to increase upon standing in response to a change in another vital sign. Question 2 of 30 The nurse plans to assess Donna for orthostatic vital sign changes. Which action will the nurse take first? Assist Donna to a standing position. During orthostatic vital sign measurement the client should be placed in another position. Position Donna 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. Elevate the head of Donna's bed. The client is assisted to a sitting position after vital signs are first measured in another position. Dangle Donna's feet at the bedside. The client is assisted to a sitting position after vital signs are first measured in another position. Question 3 of 30 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. Remove the blood pressure cuff. After the blood pressure cuff is deflated, it is left in the same position on the same arm for all three blood pressure readings. Help the client change positions. Another action should be taken before assisting the client to change positions. Assess for an auscultatory gap. Assessment for an auscultatory gap is done while the blood pressure measurement is being taken. Section 2 Assessment In addition to obtaining Donna's vital signs, the nurse performs additional assessments. Question 4 of 30 For ongoing evaluation of Donna's fluid volume status, it is most important to obtain which assessment data? Urine color. This provides valuable assessment data related to fluid volume, but it is not the most important data for ongoing evaluation of fluid volume. Capillary refill. This provides valuable assessment data regarding adequacy of tissue perfusion, which may be impacted by fluid volume, but it is not the most important assessment related to fluid volume. Body weight. Daily weights provide the most important data about fluid volume status, so an initial weight upon admission must be obtained. Skin turgor. This provides valuable assessment data related to fluid volume, but it is not the most important data for ongoing evaluation of fluid volume. The nurse continues to assess the client and observes that Courtney's skin tents when a fold of skin over her sternum is pinched. Question 5 of 30 What action should the nurse implement? Confirm this finding by pinching the skin on her hand. The elderly frequently experience inelastic skin turgor of the hands, so this is not a valuable indicator of fluid volume status. Notify the healthcare provider that the client is now retaining fluid. Tenting is not a sign of fluid retention. Advise Donna that the fluid deficit seems to be worsening. Tenting is an expected finding in a client with fluid volume deficit. Document the presence of inelastic skin turgor. Skin turgor is best assessed in the elderly 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. Section 3 Math Donna's daughter reports that her mother usually weighs about 137 lbs. and is 5 feet, 3 inches in height. The nurse weighs Donna and obtains a measurement of 60 kg. Question 6 of 30 The nurse explains to Donna's daughter that Donna has lost approximately how many pounds? 3. Try your calculation again. Remember the conversion factor from kilograms to pounds. 5. 60 kg × 2.2 = 132 lbs. 137 lbs. - 132 lbs. = 5 lbs. This represents an approximate weight loss of 5 pounds. 4. Try your calculation again. Remember the conversion factor from kilograms to pounds. 7. Try your calculation again. Remember the conversion factor from kilograms to pounds. Section 4 Age-related Risk Factors The nurse discusses factors that contributed to Donna's fluid volume deficit with Donna and her daughter. Question 7 of 30 Which problem often occurs in the elderly and may have contributed to the fluid volume deficit Donna is experiencing? Decreased hepatic blood flow. Decreased hepatic blood flow commonly occurs in the elderly. This decreases drug metabolism, which allows drugs to remain in the body longer and produces a greater drug effect. Decreased drug absorption. Factors such as decreased gastrointestinal (GI) motility and decreased GI acidity lead to changes in drug absorption time, but generally, actual drug absorption is not decreased. Decreased drug half-life. Decreased metabolism in the elderly often leads to an increase in the half-life of drugs taken by them. Decreased GI acidity. Decreased GI acidity often occurs in the elderly, but this would not be a contributing factor for this client's fluid volume deficit. The nurse is aware that the elderly often experience an increase in the amount of free, unbound drug molecules, which has the potential to increase the pharmacological effects of the drug. Question 8 of 30 Which lab test will the nurse monitor to determine if this may be a factor contributing to Donna's problem? Serum creatinine. The client's serum creatinine level will not provide useful data regarding the potential for increased amounts of free, unbound drug molecules. Serum protein. Drug molecules may be distributed through 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. AST. The client's AST level will not provide useful data regarding the potential for increased amounts of free, unbound drug molecules. BUN. The client's BUN level will not provide useful data regarding the potential for increased amounts of free, unbound drug molecules. Section 5 Intravenous Fluids The nurse starts an intravenous line to administer fluids. The prescription states, "3% Normal Saline to infuse at 100 mL/hour." The client's most recent serum sodium level is 135 mEq/L. Question 9 of 30 What action should the nurse take? Hang 0.9% Normal Saline at 100 mL/hour. The nurse does not have the authority to change the prescription unilaterally. Begin infusing the solution at a keep-open rate. Even this slow rate of administration has the potential to be harmful in this situation. Start the intravenous solution as prescribed. This solution may be harmful to this client. Obtain appropriate IV fluid prescription. Three percent saline 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 Donna 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. Section 6 Medication Errors A short while later, a prescription for 0.9% Normal Saline at 100 mL/hour is received. Donna's primary nurse is at lunch, so another nurse hangs the solution. When checking Donna upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose and 0.9% Normal Saline is infusing at 125 mL/hour. Question 10 of 30 What action should the primary nurse implement? Obtain a container of 0.9% Normal Saline to hang when the present solution has finished infusing. This action will not correct the errors that occurred. Decrease the infusion rate of the present solution to 75 mL/hour to compensate for the error made. This action will not correct the errors that occurred. Stop the IV solution currently infusing and monitor the client for signs of an anaphylactic reaction. The client is unlikely to have an anaphylactic reaction. However, this does not completely correct the error. Change the currently infusing solution to 0.9% Normal Saline 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. Section 7 Legal Consideration: Treatment Error After hanging the correct IV solution at the correct rate of infusion, the nurse discusses the error with the nurse who hung the first IV solution. Together, the nurses complete a variance (incident) report. Question 11 of 30 What additional action should the primary nurse take? Discuss the consequences of the error with the hospital legal counsel. It is not necessary for the nurse to discuss medication errors with a lawyer. 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. Report to the hospital pharmacist that a variance report was written. The variance report will be used by the healthcare agency for risk management purposes. Notify the hospital educator of the need for staff training about IV fluids. A pattern of medication errors may indicate the need for additional staff training, but this situation does not provide sufficient information to warrant that intervention. The nurse who made the errors is very upset about writing a variance (incident) report and states, "I've never made an error before. What if I get fired?" Question 12 of 30 How should the primary nurse respond? "The variance report will show that this is your first medication error." The variance report provides information about the specific event, not the pattern of errors made by an individual nurse. "As long as you understand your error, we can disregard this report." The variance report provides important data for the healthcare agency. "Since no harm was done to the client, the variance report will not matter." The variance report provides important data for the healthcare agency's risk management program. "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. Section 8 Local IV Site Complications Later that day, Donna'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. Question 13 of 30 Which intervention should the nurse take next? Apply light pressure above the site. This will create further obstruction. Lower the IV solution below the site. This is often helpful to check for the presence of a blood flashback, indicating the IV is still infusing in the vein. However, another action should be taken first. 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. Change the IV site dressing. Although dressing that is too tight may obstruct the flow of the IV solution, another action should be taken first. 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. The label on the IV site indicates the current IV has been in place for 36 hours. Question 14 of 30 Which action should the nurse take? Continue the IV with the arm elevated on a pillow. This action will not improve the situation. 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. Notify the healthcare provider that the IV site appears inflamed. The nurse is authorized to take needed action when an IV site complication occurs. Complete a variance report regarding the IV site. Variance (incident) reports are completed when a situation takes place that is inconsistent with the routine care of a client. An error in treatment has not occurred. IV site complications are an anticipated adverse effect of treatment and do not require the completion of a variance report. Section 9 Nursing Process The nurse used the nursing process in deciding to remove Donna's IV and restart it in a new location. Question 15 of 30 When assessing the IV site, what step of the nursing process did the nurse use? Analyze the data. The nurse analyzes the assessment data to determine if characteristics occur that define a problem. A problem is then stated, a goal is established, and interventions are planned and implemented. Plan interventions. This is not the next step in the nursing process. Determine the problem. This is not the next step in the nursing process. Establish a goal. This is not the next step in the nursing process. Question 16 of 30 Which problem did the nurse identify as most pertinent in that situation? Risk for impaired skin integrity. Impaired skin integrity already exists at the IV insertion site. Risk for injury (thrombus formation). The phlebitis at the IV site places Donna at high risk for thrombus formation. So, the nurse identified this problem, established the goal that the risk for injury will be reduced, and implemented the interventions of removing the IV and providing care at the site of inflammation. Fluid volume deficit. While this is pertinent to Donna's overall plan of care, it was not the priority problem in that situation. Infection. Phlebitis is an inflammatory process, not an infectious process. Section 10 Intake and Output Measurement Donna continues to receive 0.9% Normal Saline 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. Question 17 of 30 Which items should be measured as fluid intake? Select all that apply Scrambled eggs. Scrambled eggs are not measured as fluid intake. Bowl of oatmeal. Oatmeal is not measured as fluid intake. Fresh orange. An orange is not measured as fluid intake. Milk. Oral fluid intake includes only foods that are liquid at room temperature. Apple juice. Oral fluid intake includes only foods that are liquid at room temperature. When Donna was first admitted, the healthcare provider did not include intake and output measurement in the initial prescriptions, but the primary nurse initiated this assessment activity. Question 18 of 30 Now that Donna is taking oral fluids well, what action should the nurse implement? Notify the healthcare provider that a prescription to continue intake and output measurement is needed. The nurse may initiate and maintain intake and output measurement without a prescription from the healthcare provider. Continue the measurement of the client's fluid intake and output. Since Donna 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. Stop measuring the client's fluid intake and output as long as she takes oral fluids. Donna remains at risk for fluid volume alterations even though she is taking oral fluids. Measure the client's fluid output, but discontinue measuring fluid intake. The measurement of Donna's fluid intake should not be discontinued because she is still at risk for fluid volume alterations. Section 11 Fluid Volume Excess Donna's intake and output measurements indicate her intake is greater than her output. The nurse is concerned that Donna may develop fluid volume excess. Question 19 of 30 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 and result in hypoxemia. Measure the client's tympanic temperature. Changes in temperature as the result of fluid volume excess are generally not significant. Compare the client's muscle strength bilaterally. This is not a significant assessment to perform for suspected fluid volume excess. Ask the client if she is experiencing any syncope. This is not a significant assessment to perform for suspected fluid volume excess. The nurse also observes that Donna's feet and ankles are swollen. When the nurse presses a finger over the client's ankle (bony prominence), an 8 mm indentation appears. Question 20 of 30 How will the nurse document this finding? Gross edema in the lower extremities. The client is experiencing edema, but this documentation does not provide the best description of the edema. 4+ pitting edema present around ankles and feet. This documentation concisely describes the degree of indentation present and its location. Stage 1 pressure ulcer forming due to ankle edema. The indentation is not an indication of a stage 1 pressure ulcer. Blanching and induration present bilaterally. Neither blanching nor induration are indicated by this assessment. Section 12 Donna has abnormal breath sounds, bilateral pitting edema, and jugular vein distention. Question 21 of 30 Which change in Donna's pulse will the nurse anticipate? Increase in rate and volume. As fluid volume increases to the point of fluid volume excess, the client will develop tachycardia (increase in rate) and a bounding pulse (increase in volume). Decrease in rate and volume. These are not the typical changes with fluid volume excess. Increase in rate, but no change in the volume. These are not the typical changes with fluid volume excess. Decrease in rate, but no change in the volume. These are not the typical changes with fluid volume excess. Further findings include oxygen saturation level of 90%, serum sodium of 140 mEq/L, serum chloride 105 mmol/L, albumin 4 g/dL, AST 30 IU/L, and serum potassium of 3 mEq/L. Question 22 of 30 The nurse reviews the client’s laboratory results. Which laboratory result is critical and should be reported to the healthcare provider? Sodium 140. Sodium level is within normal limits. Chloride 105. Chloride level is within normal limits. Albumin 4. Albumin level is within normal limits. Potassium 3. The client’s potassium level is low and will need to be addressed by the HCP. Question 23 of 30 The nurse reports the findings to the healthcare provider and receives several prescriptions. Which prescription should the nurse question? Furosemide (Lasix) 40 mg IV push now. The administration of a diuretic is an expected prescription for a client with fluid volume excess. Potassium chloride 40 mEq PO. Donna'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. Decrease the Normal Saline to KVO. Decreasing intravenous fluid intake is an expected prescription for a client with fluid volume excess. Administer oxygen per nasal cannula at 2 L/minute. Donna's oxygen saturation level is lower than the desired range (95% to 100%). The administration of oxygen via nasal cannula is an expected prescription. Section 13 Pharmacology: Diuretics Donna's fluid volume excess improves and the prescription for hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted. Question 24 of 30 Which lab values are most important for the nurse to monitor? (Select all that apply). Select all that apply Hemoglobin. Hydrochlorothiazide, a diuretic, will not significantly impact this lab value. White blood cell count. Hydrochlorothiazide, a diuretic, will not significantly impact this lab value. Serum potassium. Hydrochlorothiazide (HydroDIURIL), a potassium-wasting diuretic, may cause significant hypokalemia. Prothrombin Time (PT/INR). Hydrochlorothiazide, a diuretic, will not significantly impact this lab value. Magnesium. Use of hydrochlorothiazide may also result in a decrease in serum magnesium and sodium and an increase in serum calcium and glucose. Question 25 of 30 The nurse will emphasize the importance of taking this medication only once a day, on what schedule? Before eating breakfast. It is not recommended to take hydrochlorothiazide on an empty stomach. 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. After lunch. This is not the best time of day to take a diuretic. At bedtime. This is not the best time of day to take a diuretic. Before Donna's discharge, the nurse provides client teaching related to the prescribed hydrochlorothiazide (HydroDIURIL). Question 26 of 30 Since Donna 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 Baked potato. 1 long potato contains 844 mg potassium. This shows that the client has an understanding of potassium-rich foods. Green beans. 1/2 cup of green beans contains 100 mg potassium. This selection shows that the client does not have a good understanding of potassium-rich foods. Chicken breast. 4 oz of chicken breast contains 458 mg potassium. This shows that the client has an understanding of potassium-rich foods. Apple. 1 apple contains 159 mg of potassium. This selection shows that the client does not have a good understanding of potassium-rich foods. Grapefruit juice. 8 oz of grapefruit juice contains 378 mg of potassium. This shows that the client has an understanding of potassium-rich foods. Section 14 Medication Administration: Oral Tablets In preparing to administer the hydrochlorothiazide, the nurse notes that the prescribed dose is 12.5 mg, and the tablet available is 25 mg. Question 27 of 30 Which action should the nurse take? Observe the tablet to see if it is scored. A scored tablet can safely be divided so that the client may receive the prescribed dose. Hydrochlorothiazide is a scored tablet, and 25 mg is the lowest tablet strength available. The nurse should therefore assess Donna's ability to break the tablet. Notify the pharmacist of the error. The tablet may not be available in the smaller dose. Another nursing action should be taken. Hold the medication until the right dose is available. The tablet may not be available in the smaller dose. Another nursing action should be taken. Document the change in dose on the medication record. The prescribed dose has not been changed. Administration of the entire tablet would result in a medication error. Upon entering Donna's room with the medication, the nurse checks Donna's identification band. Donna states, "You take care of me every day. Why do you keep looking at my identification?" Question 28 of 30 What is the best response by the nurse? "It is hospital policy to always check client identification." While this is probably correct, it is more beneficial to explain the rationale for the action to the client. "Your healthcare provider has asked that we always perform this check." This is a nursing action, not an action prescribed by the healthcare provider. "Wearing an identification band is important for all clients." This is true but does not provide client teaching that explains the importance of checking the identification band. "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. Question 29 of 30 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. Two identifiers should be used to verify that a medication will be administered to the right client by using either a bar code scanning system or at least two identifiers such as full name, date of birth, and current photograph. Date of birth. Two identifiers should be used to verify that a medication will be administered to the right client by using either a bar code scanning system or at least two identifiers such as full name, date of birth, and current photograph. Current photograph. Two identifiers should be used to verify that a medication will be administered to the right client by using either a bar code scanning system or at least two identifiers such as full name, date of birth, and current photograph. Room number. The client’s room number should not be used as an identifier. Physical location. The client’s physical location should not be used as an identifier. Question 30 of 30 The nurse is preparing discharge instructions for Donna. 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. Cognitive impairment is associated with dehydration in the older adult. Change in urine output. Decreased renal perfusion and altered renal function can compromise the client’s fluid volume status. Presence of tachycardia. Presence of tachycardia is associated with dehydration in the older adult. Tenting on arm when checking skin turgor. Tenting on arm is an expected skin change with the aging adult. Checking skin turgor on arm is not reflective of fluid volume. Longitudinal furrows on the tongue. Longitudinal furrows on the tongue are indicative of dehydration. Section 15 Case Outcome Donna'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. The nurse observes that Donna is able to break the scored medication tablet without difficulty. Donna is discharged home, accompanied by her daughter.