Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
week 12
Nursing Diagnosis and Planning Related to Fluid Imbalances
| Question | Answer |
|---|---|
| Susan assigns a nursing diagnosis of Excess Fluid Volume related to retention of excess body fluid as evidenced by edema, dyspnea, sudden weight gain, and activity intolerance. What is the selection of this nursing diagnosis based on? | Mrs. Ellis’s diagnosis of heart failure Assessment findings of dependent edema and dyspnea History of sudden weight gain |
| Mrs. Ellis exhibits clinical manifestations of fluid volume excess (FVE). In addition to the nursing diagnosis of Excess Fluid Volume, which other nursing diagnoses related to FVE could be selected for her, based on her clinical data? | Decreased cardiac output |
| After completing the nursing assessment, the nurse writes the nursing diagnosis label, Readiness for Enhanced Fluid Balance. What are the defining characteristics of this diagnostic label? | Stable daily weights Moist mucous membranes Intake equals output No manifestations of fluid volume deficit |
| Match the nursing diagnosis with the supporting evidence. - Edema, dyspnea, sudden weight gain - Dry skin and mucous membranes, sudden weight loss, decreased urine output - About to undergo a major surgical procedure - Low blood pressure, tachycardia, | Excess Fluid Volume Deficient Fluid Volume Risk for Fluid Imbalance Decreased Cardiac Output |
| The nurse writes the nursing diagnosis of Deficient Fluid Volume after performing a nursing assessment. For the nursing outcome: Achieve and maintain fluid balance, which goal statement would most directly measure this outcome? | The patient’s intake will approximately equal output during a 12-hour shift. |
| Mr. Evans and George, his nurse, jointly create patient-centered goals based on the nursing diagnosis. Which goal meets all of the criteria for correctly written goals? | The patient will consume at least 1800 mL of oral fluids during a 24-hour shift. |
| Match the role of each member of the health care team with how they help patients meet goals related to fluid balance. Advise the patient about reduced sodium diet, monitor sodium intake Assist with monitoring daily weights, vital signs, and intake and | Registered Dietician Nursing Assistant Pharmacy Physical Therapist |
| Match each element with its patient centered goal. Patient will drink 100 mL of water every hour for the 12-hour day shift. Patient will exhibit no edema of the ankles or feet for the 12-hour shift. Patient will have required fluid levels on completion | Deficient fluid volume Excess fluid volume Fluid imbalance goal |
| On assessment, the nurse notes that the patient is dyspneic and crackles are audible on lung auscultation, and that the patient has gained 1.8 kg over the past 24 hours. What nursing diagnostic label do these data suggest? | Excess fluid volume |
| A patient is preparing to undergo a major abdominal surgery. The nurse creates a care plan for this preoperative patient. Which is an appropriate nursing diagnosis related to fluid imbalance? | Risk for fluid imbalance |
| A patient has a history of nausea and vomiting for 3 days, has become increasingly lethargic, has a urine output of less than 30 mL/hour, and has a very poor oral intake. The nurse performs an assessment and finds cool pale skin, dry mucous membranes, low | Deficient Fluid Volume related to loss of fluids through nausea and vomiting as evidenced by dry mucous membranes, low blood pressure, tachycardia, and decreased urine output |
| Mrs. Ellis exhibits clinical manifestations of fluid volume excess (FVE). In addition to the nursing diagnosis of Excess Fluid Volume, what other nursing diagnoses related to FVE could be selected for her, based on her clinical data? | Decreased cardiac output |
| After completing the nursing assessment, the nurse writes the nursing diagnosis label, Readiness for Enhanced Fluid Balance. What are the defining characteristics of this diagnostic label? | Stable daily weights Moist mucous membranes Intake equals output No manifestations of fluid volume deficit |
| A patient has a nursing diagnosis of Deficient Fluid Volume related to decreased circulating volume as evidenced by low blood pressure, thready pulse, tachycardia, decreased urine output, and thirst. Which statement represents a measurable, patient-center | The patient will consume at least 100 mL of fluids every hour for a 12-hour shift. |
| A patient has a nursing diagnosis of Excess Fluid Volume related to increased fluid retention as evidenced by edema, decreased urine output, dyspnea, and activity intolerance. Which goals would be appropriate for the nurse to add to the patient’s plan of | The patient will consume no more than 1500 mg of sodium in a 24-hour period. The patient will maintain a urinary output of greater than 30mL per hour for 24 hours. The patient will be able to walk 50 feet without dyspnea by the end of a 12-hour shift. |
| The nurse writes the nursing diagnosis of Excess Fluid Volume after performing a nursing assessment. For the nursing outcome: Achieve and maintain fluid balance, which goal statement would most directly measure this outcome? | The patient’s intake and output will be approximately equal during a 24-hour day. |
| The nurse writes the nursing diagnosis of Deficient Fluid Volume after performing a nursing assessment. For the nursing outcome: Achieve and maintain fluid balance, which goal statement would most directly measure this outcome? | The patient’s intake will approximately equal output during a 12-hour shift. |
Created by:
Brandi Sizemore
Popular Nursing sets