The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take?
a. Encourage copious amounts of water.
b. Start an additional intravenous (IV) line.
c. Measure and record all intake and output.
d. Weigh the patient and compare with preoperative weight.
ANS: C
Accurate recording of intake and output assesses renal and circulatory function. Measure and record all sources of intake and output. Encouraging copious amounts of water in a postoperative patient might encourage nausea and vomiting. In the PACU, it is impractical to weigh the patient while waking from surgery, but in the days afterward, it is a good assessment parameter for fluid imbalance. Starting an additional IV is not necessary and is not important at this juncture.
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