The physician asks the nurse to monitor the fluid volume status of a congestive heart failure pa-tient and a patient at risk for clinical dehydration. What is the most effective nursing intervention for monitoring both of these patients?
a. Weigh the patients every morning before breakfast.
b. Ask the patients to record their intake and output.
c. Measure the patients' blood pressure every 4 hours.
d. Assess the patients for edema in extremi-ties.
ANS: A
An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with ECV deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration.
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