Questions to Answer:
1. Which guidelines should the nurse follow when calculating a client’s fluid
intake?
2. A client is unresponsive and breathing agonally after cardiopulmonary
resuscitation has been provided. The family asks about "do not resuscitate"
(DNR) because of their concern with aggressive treatment with all that has
been provided. What is the role of the provider in this situation?
3. Describe two (2) priority nursing considerations for a client who appears to be
having an allergic reaction to his medication.
1. Which guidelines should the nurse follow when calculating a client’s fluid
intake?
Nurses should document all fluids consumed by the client, including oral fluids, intravenous fluids, and
any fluids administered through enteral or parenteral nutrition. It is important to record the type of
fluid, the amount consumed, and the time it was consumed.
Nurses should also consider the client's medical condition, such as any fluid restrictions or requirements.
They should work closely with the healthcare team to ensure the client receives the appropriate amount
of fluids to maintain their fluid and electrolyte balance.
It is important for nurses to accurately measure and record fluid intake to ensure the client's fluid status
is accurately assessed and any necessary adjustments to their treatment plan are made in a timely
manner.
In addition to measuring and recording the client's fluid intake, nurses should also monitor the client's
urine output. This helps to assess the client's fluid balance and kidney function. Nurses should report
any changes in the client's urine output to the healthcare team.
Nurses should also consider the client's age, weight, and underlying medical conditions when calculating
their fluid intake. For example, elderly clients or those with kidney disease may require more careful
monitoring of their fluid intake and output.
It is important for nurses to be aware of the signs and symptoms of fluid imbalance, such as edema,
shortness of breath, or decreased urine output. If any of these symptoms occur, nurses should promptly
report them to the healthcare team and initiate appropriate interventions.
Overall, nurses should follow their facility's policies and procedures when calculating and monitoring a
client's fluid intake. Accurate and timely documentation, close monitoring of urine output and
symptoms of fluid imbalance, and collaboration with the healthcare team are essential to ensuring the
client's safety and well-being.
Nurses should also take into consideration the client's daily activity level, as well as any losses of fluids
from drains, wounds, or ostomies, when calculating their fluid intake. They should document these
losses and ensure they are taken into account when determining the client's overall fluid balance.
Nurses should also ensure that the equipment used to measure fluid intake is accurate and calibrated
properly. This includes measuring cups, pitchers, and IV pumps. They should document the equipment
used and any calibration or maintenance performed on the equipment.
Finally, nurses should educate clients and their families on the importance of maintaining a proper fluid
balance and monitoring fluid intake. They should provide instructions on how to accurately measure and
