The nurse is caring for a patient with the diagnosis of Fluid Volume Excess. Which information should the LPN/LVN use to determine if care was effective?
a. Restrict the patient's fluid intake.
b. Measure the patient's daily weight.
c. Teach the patient to monitor fluid balance.
d. Discuss the patient's care plan with the RN.
ANS: B
B. To evaluate the effectiveness of the plan of care and the actions implemented, the nurse must assess the outcome for the patient's nursing diagnosis and determine if the outcome has been achieved or if revisions are needed. For this patient, a change in weight is an objective measurement for determining if interventions to address Fluid Volume Excess have been effective. A. Restricting fluid intake is an action. Evaluation is required to determine patient outcome and effective care. C. Teaching the patient to monitor fluid balance is an intervention and will not help determine the effectiveness of care. D. Although discussing the plan of care with the RN is relevant to the patient's care, it will not help determine effectiveness of care provided.
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