An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss
An individualized nursing goal identified for this client is "The client will maintain urine output of at least 30 mL/hour." Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct.
1) Measure and record urine output every hour; report an output of less than 30 mL/hour.
2) Monitor skin turgor and moistness of mucous membranes every shift.
3) Administer intravenous (IV) fluids as prescribed.
4) Keep oral fluids within the patient's reach and encourage the patient to drink.
ANS: 1, 3, 4
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