A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following:
T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results:
Sodium 138 mEq/L
Potassium 3.7 mEq/L
Calcium 9.2 mg/dL
Magnesium 1.8 mg/dL
Chloride 99 mEq/L
BUN 29 mg/dL
Which of the following is an appropriate nursing diagnosis for this patient?
a. Impaired Gas Exchange related to ineffective breathing
b. Excess Fluid Volume related to limited fluid output
c. Deficient Fluid Volume related to abnormal fluid loss
d. Electrolyte Imbalance related to decreased oral intake
C
Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume. There is no information to indicate that she has respiratory problems or Impaired Gas Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte Imbalance is not a nursing diagnosis.
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