A client with severe malnutrition has pedal edema and ascites. The nurse notes that the weight is unchanged for the last 2 days. The most appropriate action by the nurse is to
a. ask the assistive personnel to re-weigh the client.
b. assess vital signs, level of consciousness, and urine output.
c. call the physician to request IV diuretics.
d. have biomedical engineering check the scale.
B
Manifestations of third-spaced fluids are similar to those of dehydration because the fluid is not in the vascular space. However, body weight does not change because the fluid has not been lost; it has just been redistributed. In this client, the malnutrition has probably led to a decrease in se-rum albumin level, leading to decreased oncotic pressure and the fluid shifts. The nurse should assess the client further for manifestations of hypovolemia because severe shock can result. IV fluids need to be continued until there is evidence that the fluid is returning to the vascular space.
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