The nursing student is caring for an infant with a respiratory infection and is monitoring for signs of dehydration. The nursing instructor asks the student to identify the most reliable method of determining fluid loss
The instructor determines that the student understands this method when the student states that the plan is to: 1. Monitor output.
2. Monitor body weight.
3. Assess the mucous membranes.
4. Obtain a temperature every 2 hours.
2
Rationale: Body weight is the most reliable method of measuring body fluid loss or gain. One kilogram of weight change represents 1 L of fluid loss or gain. "Monitor output," "assess the mucous membranes," and "obtain a temperature every 2 hours" are also appropriate measures to assess for dehydration, but the most reliable method is to monitor body weight.
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Which interventions should a nurse include in the plan of care for a woman who has been physically abused by a partner for 10 years? Select all that apply
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