Nursing Assessment of Fluid and Electrolyte Imbalances
Nursing Assessment of Fluid and Electrolyte Imbalances ( 5 Questions)
A nurse is caring for a client who has fluid volume excess. Which of the following actions should the nurse take? (Select all that apply.)
Monitoring daily weight is an important action for the nurse to take because it reflects the fluid status of the client. A sudden increase in weight indicates fluid retention, while a sudden decrease indicates fluid loss. The nurse should weigh the client at the same time every day, using the same scale and clothing.
Restricting sodium intake is another action that the nurse should take because sodium attracts water and increases fluid volume. The nurse should limit or avoid foods that are high in sodium, such as processed meats, canned soups, cheese, pickles, and salty snacks. The nurse should also educate the client about reading food labels and choosing low-sodium alternatives.
Administering diuretics as prescribed is a third action that the nurse should take because diuretics increase urine output and reduce fluid volume. The nurse should monitor the client's electrolyte levels, blood pressure, and urine output before and after giving diuretics. The nurse should also inform the client about the possible side effects of diuretics, such as dehydration, hypotension, hypokalemia, and ototoxicity.
Encouraging oral fluids is not an action that the nurse should take because it would worsen the fluid volume excess. The nurse should limit or restrict oral fluids as ordered by the provider. The nurse should also measure and record all fluid intake and output accurately.
Elevating the head of the bed is a fourth action that the nurse should take because it improves respiratory function and reduces pulmonary congestion. The nurse should elevate the head of the bed to at least 30 degrees or more, depending on the client's comfort and tolerance. The nurse should also monitor the client's oxygen saturation, breath sounds, and dyspnea.
Choice A reason:
Monitoring daily weight is an important action for the nurse to take because it reflects the fluid status of the client. A sudden increase in weight indicates fluid retention, while a sudden decrease indicates fluid loss. The nurse should weigh the client at the same time every day, using the same scale and clothing.
Choice B reason:
Restricting sodium intake is another action that the nurse should take because sodium attracts water and increases fluid volume. The nurse should limit or avoid foods that are high in sodium, such as processed meats, canned soups, cheese, pickles, and salty snacks. The nurse should also educate the client about reading food labels and choosing low-sodium alternatives.
Choice C reason:
Administering diuretics as prescribed is a third action that the nurse should take because diuretics increase urine output and reduce fluid volume. The nurse should monitor the client's electrolyte levels, blood pressure, and urine output before and after giving diuretics. The nurse should also inform the client about the possible side effects of diuretics, such as dehydration, hypotension, hypokalemia, and ototoxicity.
Choice D reason:
Encouraging oral fluids is not an action that the nurse should take because it would worsen the fluid volume excess. The nurse should limit or restrict oral fluids as ordered by the provider. The nurse should also measure and record all fluid intake and output accurately.
Choice E reason:
Elevating the head of the bed is a fourth action that the nurse should take because it improves respiratory function and reduces pulmonary congestion. The nurse should elevate the head of the bed to at least 30 degrees or more, depending on the client's comfort and tolerance. The nurse should also monitor the client's oxygen saturation, breath sounds, and dyspnea.