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Sherpath: Fluid Balance:
Implement and Take Action and
Evaluate
Which assessments would the nurse closely monitor as indicators of changes in a patient's fluid volume status? Vital signs Daily weights Intake and output Which substances would the nurse include in a patient's fluid intake tally at the end of 24 hours? IV fluids a dish of cherry-flavored gelatin Supplemental enteral feedings Which measurements would the nurse include in a patient's fluid output tally at the end of the day? Urine in a urinary catheter collection bag Emesis caused by a vomiting episode
Which items are commonly used as measuring tools for urine output? Urine hat Diaper Urinal Indwelling catheter Which factors would a nurse consider when planning fluid intake for a patient on a 1200 mL fluid restriction plan? Meals Medications Intravenous (IV) fluid intake Between-meal fluids A patient has been placed on fluid restriction for management of fluid volume excess. Which actions would the nurse take to ensure the alert, adult 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. Which action would the nurse take after noting that at 1:00 p.m. a patient on a fluid restriction has consumed 800 mL of the daily allotted 1200 mL? Involve the patient in planning how to budget the remaining 400 mL over the remainder of the day.
Hypertonic crystalloid 5% dextrose and 0.9% normal saline A patient receiving an intravenous (IV) crystalloid infusion reports that the IV site hurts. The nurse notes redness, swelling, and warmth at the IV site. Which complications would the nurse consider as a result of these signs and symptoms? Phlebitis Catheter-related infection Which major uses of a central venous catheter (CVC) would a nurse recognize? Long-term intravenous (IV) therapies Short-term intensive therapies Administering hypertonic solutions Which patients are candidates for blood or blood product administration? A patient with missing clotting factors A patient with drug-related destruction of red blood cells A patient with abdominal bleeding from trauma A patient who has had recent major surgery Which individuals are responsible for checking and verifying blood prior to administration?
Personnel in the blood bank Nurse who picks up the blood from the blood bank Two nurses at the patient's bedside before initiating transfusion The nurse must ensure that a blood product is infused within _______ hours after leaving the blood bank? 4 Which data reflect the priority assessments that a nurse would monitor when concerned that a patient may be developing a fluid volume imbalance? 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 ,, Which substances would a nurse need to include in the fluid intake tally? Nasogastric (NG) tube irrigations Enteral tube feedings Free water gastric tube flushes Intravenous medications Which patient-related data would require entry of fluid output information on the electronic health record (EHR)?
The nurse suspects that a patient receiving an intravenous (IV) infusion of D5 0.45% NS is developing intracellular dehydration and circulatory overload. For which reason would this IV solution cause this complication? It is a hypertonic solution. Which intravenous (IV) site in infants is most commonly used? The vein in the middle of the scalp Which actions related to intravenous (IV) fluid administration are the responsibility of the registered nurse? 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. Which complications would a nurse need to monitor for when caring for a patient receiving a hypertonic intravenous (IV) fluid? Cellular dehydration Circulatory overload Air embolism Which intravenous (IV) solution would a nurse use to prime the IV tubing when preparing to administer a blood product? 0.9% normal saline
Which procedural step failure would a nurse recognize as the most common cause of adverse blood transfusion events? Inappropriate identification prior to blood administration During which time period would the nurse ensure extra vigilance when administering a blood product? As the transfusion is started and within the first 15 minutes Which signs or symptoms of an adverse reaction would a nurse monitor for in a patient who is receiving a unit of blood? Itching Hypotension Dyspnea Fever
