BSN 205 Fluid and Electrolytes - Questions, Answers and Rationales Susan assigns a nursing diagnosis of Excess Fluid Volume related to retention of
... [Show More] excess body fluid as evidenced by edema, dyspnea, sudden weight gain, and activity intolerance. What is the selection of this nursing diagnosis based on? Select all that apply. Mrs. Ellis's diagnosis of heart failure Primary care provider's diagnosis Assessment findings of dependent edema and dyspnea History of sudden weight gain Increased urine output Mrs. Ellis exhibits clinical manifestations of fluid volume excess (FVE). In addition to the nursing diagnosis of Excess Fluid Volume, which other nursing diagnoses related to FVE could be selected for her, based on her clinical data? Impaired mobility Decreased cardiac output Readiness for Enhanced Fluid Balance Risk for Imbalanced Fluid Volume The decreased urine output and lethargy indicates that the patient's fluid volume excess is having an impact on the cardiac workload and 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? Select all that apply. Stable daily weights Moist mucous membranes Intake equals output No manifestations of fluid volume deficit Absence of or mild dependent edema 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 systolic blood pressure will remain above 90 for 24 hours. The patient's intake will approximately equal output during a 12-hour shift. The patient will consume 100 mL of oral fluids each hour during a 12-hour shift. The patient will have no dryness or cracking of mucous membranes by the end of the shift. This patient-centered goal directly addresses the desired outcome of fluid balance. Mr. Evans and George, his nurse, jointly create patient-centered goals based on the nursing diagnosis. Which goal meets all of the criteria for correctly written goals? The patient will consume at least 1800 mL of oral fluids during a 24-hour shift. The patient will maintain a normal blood pressure for a 12-hour shift. The patient will maintain an adequate hourly urine output for a 24-hour period. Increase IV fluids as needed This goal is correctly stated and meets all of the goals statement criteria. It is patient-centered, measurable, specific, and includes a time frame. Match the role of each member of the health care team with how they help patients meet goals related to fluid balance. Advise the patient about reduced sodium diet, monitor sodium intake - Registered Dietician Assist with monitoring daily weights, vital signs, and intake and output - Nursing Assistant Monitor continued need for medications and ensure correct dosage - Pharmacy Assist in meeting ambulation, mobility goals; improve physical conditioning - Physical Therapist Match each element with its patient centered goal. Patient will drink 100 mL of water every hour for the 12-hour day shift. Deficient fluid volume Patient will exhibit no edema of the ankles or feet for the 12-hour shift. Excess fluid volume Patient will have required fluid levels on completion of treatment. Fluid imbalance goal 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? Risk for imbalanced fluid volume Excess fluid volume Deficient fluid volume Decreased cardiac output 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?
Excess Fluid Volume Deficient Fluid volume Decreased cardiac output 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 Risk for fluid imbalance with risk factors of loss of blood and low blood pressure Impaired skin integrity related to low blood pressure as evidenced by dry mucous membranes, cool, dry skin, and low urine output Activity intolerance related to edema as evidenced by lethargy and decreased urinary 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? Impaired mobility Decreased cardiac output Readiness for Enhanced Fluid Balance Risk for Imbalanced Fluid Volume 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? Select all that apply. Stable daily weights Moist mucous membranes Intake equals output No manifestations of fluid volume deficit Absence of or mild dependent edema 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? [Show Less]