Fluid & Electrolyte Q 56 - Gyan Darpan : Learning Portal
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Tuesday, 29 March 2022

Fluid & Electrolyte Q 56

A client with a very dry mouth, skin, and mucous membranes is diagnosed with dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?
    A. Assessing urinary intake and output.
    B. Obtaining the client's weight weekly at different times of the day.
    C. Monitoring arterial blood gas (ABG) results.
    D. Maintaining I.V. therapy at the keep-vein-open rate.

Correct Answer: A. Assessing urinary intake and output.

For the client with fluid volume deficit, assessing the client’s urine output (using a urometer if necessary) is essential to ensure an output of at least 30 ml/hour. Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours. A normal urine output is considered normal not less than 30ml/hour. Concentrated urine denotes fluid deficit.

Option B: The client should be weighed daily, not weekly, and at the same time each day, usually in the morning. Weigh daily with the same scale, and preferably at the same time of day. Weight is the best assessment data for possible fluid volume imbalance. An increase of 2 lbs a week is considered normal.
Option C: Monitoring ABGs is not necessary for this client. Rather, serum electrolyte levels would most likely be evaluated. Monitor serum electrolytes and urine osmolality, and report abnormal values. Elevated blood urea nitrogen suggests fluid deficit. Urine-specific gravity is likewise increased.
Option D: The client also would have an I.V. rate of at least 75 ml/hour, if not higher, to correct the fluid volume deficit. Administer parenteral fluids as prescribed. Consider the need for an IV fluid challenge with an immediate infusion of fluids for patients with abnormal vital signs.

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