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?

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

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.

Answer and Explanation

The Correct Answer is B

Choice A reason: Reporting only the exact intake to the physician’s nurse is incomplete, as fluid status requires balancing intake with output. Intake alone does not indicate hydration or overload, risking misinformed decisions. Comparing intake and output provides a full picture, per fluid balance assessment principles.

Choice B reason: Comparing total intake and output over 24 hours accurately assesses fluid status, as it reveals imbalances like dehydration (output > intake) or retention (intake > output). This guides interventions, ensuring proper fluid management, aligning with physiological monitoring and clinical assessment standards.

Choice C reason: Comparing intake to a normal range is useful but insufficient without output data. Normal intake varies, and fluid status depends on balance. This approach misses output-related issues like oliguria, reducing its accuracy for assessing hydration, per fluid and electrolyte management guidelines.

Choice D reason: Including intake in verbal reports is important but does not directly assess fluid status. Comparison of intake and output is needed to evaluate balance, guiding clinical decisions. Reporting alone risks overlooking imbalances, per nursing documentation and fluid assessment protocols.

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Correct Answer is A

Explanation

Choice A reason: Crackles indicate fluid or mucus in alveoli, often from pneumonia or pulmonary edema. Deep breathing and coughing mobilize secretions, potentially clearing airways. Repeating auscultation assesses if crackles persist, guiding diagnosis. This intervention enhances gas exchange by clearing alveoli, reducing hypoxia risk, and is the first step before escalating care.

Choice B reason: Limiting fluid intake to less than 2,000 mL/day is inappropriate without a diagnosis like heart failure. Crackles suggest alveolar fluid, but restricting fluids could worsen dehydration in infections like pneumonia. Deep breathing and coughing are prioritized to clear airways, improving oxygenation, while fluid restriction requires medical evaluation of underlying causes.

Choice C reason: Preparing antibiotics assumes a bacterial infection, but crackles may stem from non-infectious causes like pulmonary edema. Antibiotics target bacterial cell walls but are premature without confirmed infection. Repeating auscultation after coughing assesses airway clearance, guiding whether further diagnostic tests or treatments, like antibiotics, are needed based on findings.

Choice D reason: Semi-Fowler’s position aids breathing but does not address crackles directly. Crackles indicate fluid or mucus obstructing alveoli, impairing gas exchange. Deep breathing and coughing mobilize secretions, potentially resolving crackles, while positioning is a supportive measure. Repeating auscultation after coughing is the priority to assess airway clearance and guide interventions.

A. Urinary status B. Skin turgor C. Pain level D. Bowel sounds

Correct Answer is D

Explanation

Choice A reason: Urinary status, such as output, monitors hydration and kidney function post-surgery but is unrelated to safe oral intake. Abdominal surgery risks paralytic ileus, where intestinal motility ceases, increasing aspiration risk if food is consumed. Bowel sounds indicate gastrointestinal function recovery, making urinary status a secondary consideration for dietary decisions.

Choice B reason: Skin turgor assesses hydration but does not determine readiness for oral intake post-surgery. Abdominal surgery can impair peristalsis, causing ileus, which risks vomiting or obstruction if food is introduced prematurely. Assessing bowel sounds confirms intestinal motility, critical for safe eating, while skin turgor is irrelevant to gastrointestinal recovery.

Choice C reason: Pain level is important for patient comfort but not the primary consideration for eating post-surgery. Pain may indicate complications, but absent bowel sounds suggest ileus, a condition where the gut lacks motility, risking aspiration. Bowel sounds confirm peristalsis, ensuring safe digestion, making pain a secondary factor in this context.

Choice D reason: Bowel sounds indicate gastrointestinal motility, critical after abdominal surgery to prevent complications like ileus. Absent sounds suggest impaired peristalsis, increasing risks of vomiting or obstruction if food is consumed. Auscultating active bowel sounds confirms the gut’s readiness to process food, making this the primary consideration before allowing eating to ensure safety.

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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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