A client with cardiomyopathy receiving diuretic therapy has a urine output of 300 cc in 8 hours. Which of the following should the nurse do to assist this client?
1. This is a normal urine output, and the nurse does not need to do anything in addition to help the client.
2. Notify the physician since the client could be dehydrated
3. Assist the client to ambulate
4. Measure abdominal girth as a true assessment of the client's fluid status
2. Notify the physician since the client could be dehydrated
Rationale:
The nurse should notify the physician since a urine output of 300 cc in 8 hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. This is not a normal urine output. The nurse should not assist the client out of bed to ambulate at this time. Daily weights are an objective measurement of fluid volume and not abdominal girth.
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