A nurse measures a patient's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse do with the information?

Compare the total intake and output of fluids for the 24 hours.

Compare the patient's intake with the normal range of adult fluid intake.

Ensure the information is included in the verbal end-of-shift report.

Report the exact milliliter of intake to the physician's office nurse.

Answer and Explanation

The Correct Answer is A

a) Compare the total intake and output of fluids for the 24 hours: To assess fluid balance and status, the nurse must compare the intake and output of fluids. This helps to determine whether the patient is retaining or losing fluids.

b) Compare the patient's intake with the normal range of adult fluid intake: While this is useful for understanding general fluid needs, it does not directly assess the patient's fluid status. The comparison should be between intake and output.

c) Ensure the information is included in the verbal end-of-shift report: While this is good practice, the focus should be on using the information to assess the patient's fluid balance.

d) Report the exact milliliter of intake to the physician's office nurse: The exact intake should be recorded in the patient's chart and used for clinical decision-making, but it does not need to be reported to a physician's office nurse unless specified.

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Correct Answer is A

Explanation

a) Discontinue the feedings and notify the physician of your assessment findings: These are signs of feeding intolerance or possible complications such as delayed gastric emptying, infection, or dumping syndrome. Stopping the feeding prevents further distress, and the physician should be informed promptly.

b) Continue feedings as ordered: Continuing feedings may worsen the symptoms and put the patient at risk for aspiration or further gastrointestinal complications.

c) Administer prn pain medication: Pain medication will not address the underlying issue of nausea, vomiting, and GI symptoms. It may also mask symptoms or cause further GI upset.

d) This is a normal response, continue feedings as ordered: These symptoms are not normal. Nausea, vomiting, distention, and frequent diarrhea suggest a problem with the feeding regimen.

A. Nothing by mouth B. Nocturnal feedings only C. Administer by mouth D. Aspirate gastric contents

Correct Answer is A

Explanation

a) Nothing by mouth: NPO stands for "Nil Per Os" in Latin, which means "nothing by mouth." This includes all food and fluids, and the patient would receive nutrition through other means such as enteral feedings.

b) Nocturnal feedings only: NPO refers to not taking anything by mouth at all, not just during certain times.

c) Administer by mouth: This would contradict the NPO order, which specifies that nothing should be taken orally.

d) Aspirate gastric contents: This is a procedure used for other purposes (like verifying placement of a tube), but it does not define what "NPO" means.

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A nurse measures a patient's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse do with the information?

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Correct Answer is A

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Correct Answer is A

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