A nurse is evaluating the 24-hr 1&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
Intake 2,400 mL, output 2.500 mL
Intake 1,200 mL, output 700 mL
Intake 800 mL output 2,100 mL
Intake 2.500 mL output 500 mL
The Correct Answer is A
A. This indicates a slight positive fluid balance (+100 mL), meaning the client has taken in slightly more fluids than they have excreted. This could be acceptable depending on the client's clinical condition and fluid status.
B. This indicates a negative fluid balance (-500 mL), suggesting the client has excreted more fluids than they have taken in. In some situations, such as in patients with certain conditions like edema, a negative balance might be intended.
C. This indicates a significant negative fluid balance (-1,300 mL), where the client has excreted much more fluid than they have taken in. This could indicate dehydration or fluid loss that needs to be addressed promptly.
D. This indicates a significant positive fluid balance (+2,000 mL), where the client has taken in much more fluid than they have excreted. This could indicate fluid retention, which might be acceptable in certain clinical conditions but could be problematic in others, such as in patients with congestive heart failure.
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Related Questions
Correct Answer is D
Explanation
D. Administering the injection in the love handles, 2 inches from the umbilicus. It is important not to remove the air bubble from the prefilled syringe, as it is designed to ensure the entire dose of medication is administered.
A. Enoxaparin should not be transferred into another syringe unless specifically instructed by the manufacturer or pharmacy guidelines. Pre-filled syringes are designed to deliver the correct dose accurately and safely.
B. It is important not to remove the air bubble from the prefilled syringe, as it is designed to ensure the entire dose of medication is administered.
C. A 30-degree angle is too shallow for subcutaneous injections and may result in the medication being deposited too close to the skin surface, potentially causing irritation or affecting absorption.
Correct Answer is B
Explanation
B. Daily weight measurements are a practical and effective method to assess fluid balance. Changes in weight can reflect fluid retention or loss. Daily weighing is particularly useful for monitoring fluid status in patients with known or suspected fluid excess. It helps detect trends over time and guides adjustments in fluid management.
A. While diagnostic tests are crucial for assessing underlying causes and complications of fluid imbalance, they do not directly provide a real-time assessment of fluid balance or volume overload.
C. Monitoring IV fluid intake provides information on the amount of fluid input but does not directly indicate how the patient's body is handling or retaining that fluid. It complements other methods like daily weight measurements.
D. Vital signs are essential for assessing the hemodynamic status and response to fluid therapy but are not specific enough to quantify fluid balance or detect mild fluid excess without other signs.
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