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concept of nursing 2
nursing diagosis and planning related to fluid imbalance
| Question | Answer |
|---|---|
| On assessment, the nurse notes that the patient is dyspneic and crackles are audible on lung auscultation, and that the patient has gained 1.8 kg over the past 24 hours. What nursing diagnostic label do these data suggest? | Excess fluid volume |
| A patient is preparing to undergo a major abdominal surgery. The nurse creates a care plan for this preoperative patient. Which is an appropriate nursing diagnosis related to fluid imbalance? | Risk for fluid imbalance |
| A patient has a history of nausea and vomiting for 3 days, has become increasingly lethargic, has a urine output of less than 30 mL/hour, and has a very poor oral intake. The nurse performs an assessment and finds cool pale skin, | -- |
| dry mucous membranes, low blood pressure, tachycardia, and lethargy. Which is an appropriate nursing diagnosis? | Deficient Fluid Volume related to loss of fluids through nausea and vomiting as evidenced by dry mucous membranes, low blood pressure, tachycardia, and decreased urine output |
| Mrs. Ellis exhibits clinical manifestations of fluid volume excess (FVE). In addition to the nursing diagnosis of Excess Fluid Volume, what other nursing diagnoses related to FVE could be selected for her, based on her clinical data? | Decreased cardiac output |
| After completing the nursing assessment, the nurse writes the nursing diagnosis label, Readiness for Enhanced Fluid Balance. What are the defining characteristics of this diagnostic label? | -Stable daily weights -Moist mucous membranes -Intake equals output -No manifestations of fluid volume deficit |
| A patient has a nursing diagnosis of Deficient Fluid Volume related to decreased circulating volume as evidenced by low blood pressure, thready pulse, tachycardia, decreased urine output, and thirst. | -- |
| Which statement represents a measurable, patient-centered goal? | The patient will consume at least 100 mL of fluids every hour for a 12-hour shift. |
| A patient has a nursing diagnosis of Excess Fluid Volume related to increased fluid retention as evidenced by edema, decreased urine output, dyspnea, and activity intolerance. | -- |
| Which goals would be appropriate for the nurse to add to the patient’s plan of care? | -The patient will consume no more than 1500 mg of sodium in a 24-hour period. -The patient will maintain a urinary output of greater than 30mL per hour for 24 hours -The patient will be able to walk 50 feet without dyspnea by the end of a 12-hour shift. |
| The nurse writes the nursing diagnosis of Excess Fluid Volume after performing a nursing assessment. For the nursing outcome: Achieve and maintain fluid balance, which goal statement would most directly measure this outcome? | The patient’s intake and output will be approximately equal during a 24-hour day. |
| The nurse writes the nursing diagnosis of Deficient Fluid Volume after performing a nursing assessment. For the nursing outcome: Achieve and maintain fluid balance, which goal statement would most directly measure this outcome? | The patient’s intake will approximately equal output during a 12-hour shift. |
Created by:
Lightnning54
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