Which nursing intervention(s) would be performed for a patient who is on diuretic therapy? (Select all that apply.)
a. Auscultation of lung sounds
b. Assessment of skin turgor
c. Initiation of electrolyte supplements
d. Positioning techniques
e. Monitoring of intake and output
ANS: A, B, D, E
Lungs should be auscultated to detect the presence of fluid as a result of heart failure. Skin turgor is directly related to the degree of hydration. Skin that is well hydrated is elastic and rapidly returns to a flat position after being pinched. In dehydrated patients, the skin remains in a peaked or pinched position and returns very slowly to the flat, normal position. Positioning techniques are essential to avoid skin breakdown resulting from edema or dehydration. Assessment of intake and output will assist in determining the effectiveness of diuretic therapy. The health care provider, not the nurse, will determine the need for electrolyte supplementation. When ordered, the nurse will administer the appropriate replacements. Maintaining the ordered diet therapy is within the role of the nurse.
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