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concept of nursing 2
Implementation and Evaluation of Interventions Related to Fluid Balance
| Question | Answer |
|---|---|
| The nurse has become concerned that a patient may be developing a fluid volume imbalance. Which data reflect the priority assessments that the nurse should monitor on this patient? | -The patient’s pulse and blood pressure -The patient’s weight changes over the past day -The patient’s intake and output balance over the past 48 hours |
| The nurse is preparing to tally up a patient’s fluid intake at the end of the shift. Which substances should be included in the fluid intake tally? | -Nasogastric tube irrigations -Enteral tube feedings -Free water gastric tube flushes -Intravenous medications |
| The nurse is tallying up a patient’s intake and output at the end of the shift. Which patient-related data would require entry of fluid output information on the EHR? | -The patient has a nasogastric tube attached to wall suction. -The patient has a Foley catheter in place. -The patient has a surgical wound drain on his abdomen. |
| Which of Mrs. Walters’ assessments will Julie, her nurse, need to closely monitor as indicators of changes in her fluid volume status? | -vital sign -daily weight -intake out output |
| The nurse has received a “force fluids” order for a patient with a fluid volume deficit. Which actions taken by the nurse would be beneficial for meeting the patient’s fluid replacement needs? | -Ensuring the pitcher of water at the patient bedside is refilled as required -Providing ways to record intake of fluids to meet required levels -Tapering off fluid intake so the least amount is ingested before bedtime -reminding the patient to drink |
| The nurse is developing a 24-hour fluid budget for a patient with 1000 mL fluid restriction. The fluid budget will need to include which set of factors? | -Medications -IV fluids -Between meal fluid sipping -Breakfast, lunch, and dinner |
| A patient is on a 1000 mL per day fluid restriction. At 3 pm, the patient has consumed 700 mL. What is the best plan for the remainder of the day to maintain that fluid restriction? | -Allow 150 mL with dinner and 150 mL for medications and prior to going to sleep. |
| When addressing fluid restriction in a patient with fluid volume excess, what actions should the nurse take to ensure the patient is responsible and comfortable meeting the fluid restriction goals? | Involve the patient, if possible, and plan to space small amounts of fluid intake throughout the day. |
| The nurse suspects that a patient receiving an IV infusion of D5 0.45% NS is developing intracellular dehydration and circulatory overload. The nurse is aware that this IV solution can cause these complications due to what tonicity? | It is a hypertonic solution. |
| The nurse is inspecting an infant to identify a suitable IV site. In infants, the most common location for an IV site is which vein location? | The vein in the middle of the scalp |
| What are the nurse’s responsibilities regarding IV fluid administration? | -Verify that the fluid is appropriate for the patient. -Evaluate the effectiveness of IV therapy. -Monitor the patient for complications of IV therapy. -Comply with the 6 rights of safe medication administration. |
| The nurse is assigned to a patient who is receiving 0.9% Normal Saline IV fluid. The nurse will need to monitor the patient for what IV solution-related complication? | Hypernatremia |
| The nurse is preparing to administer a blood product. The nurse will prime the IV tubing with what IV solution? | 0.9% normal saline |
| The nurse is preparing to start a blood transfusion. The nurse is aware that the most common cause of adverse blood transfusion events is what procedural step failure? | Inappropriate identification prior to blood administration |
| When administering blood to a patient, the nurse knows that the most vigilant monitoring of the patient must take place. When must this monitoring happen? | As the transfusion is started and within the first 15 minutes |
| The nurse is monitoring a patient for possible adverse effects while receiving a unit of blood. What common manifestations does the nurse assess the patient for? | -Itching -Hypotension -Dyspnea -Fever |
Created by:
Lightnning54
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