A client is admitted for a cardiac arrhythmia secondary to anorexia nervosa. To ensure the client is receiving adequate hydration, the nurse should:

Question

1. Watch the client drink at all times.
2. Weigh the client after breakfast every other day.
3. Monitor strict intake and output.
4. Keep an intravenous fluid device in the client's room as a reminder that it will be used if the client does not drink.

Answer 1

3. Monitor strict intake and output.

Rationale:
The nurse should maintain accurate records of intake and output. Accurate daily weights are also needed; however, the client should be weighed at the same time every day, immediately upon arising, and on the same scale. The nurse can also assess and document daily the condition of the skin and oral mucous membranes as well as pulses and blood pressure, and monitor laboratory values, particularly urine specific gravity, reporting significant alterations to the physician. The nurse will not be able to watch the client drink at all times. An intravenous fluid device should not be kept in the client's room as a threat.