Fluid Balance: Analyze Cues and Prioritize Hypotheses; Plan and Generate Solutions: Sherpath

Question 1 of 6

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Which hypothesis would a nurse generate when caring for a patient with the relevant cues of dyspnea, crackles audible on lung auscultation, and weight gain of over 1.8 kg over the past 24 hours?

• • Risk for fluid volume imbalanceThis hypothesis is relevant when a patient is at risk for the problem but currently has no imbalance. The patient in the scenario has signs of a fluid volume excess.
• Correct
  • Fluid volume excessThe defining characteristics of this hypothesis are dependent edema, weight gain of 1.5 kg in 24 hours, jugular venous distension, crackles in lungs, dyspnea, and intake greater than output. The patient meets these criteria. The nurse should investigate further.
• • Impaired Fluid IntakeDeficient fluid volume includes defining characteristics such as dry mucous membranes, weight loss of 2 kg in 24 hours, thirst, orthostatic hypotension, prolonged capillary refill, and history of vomiting. The patient in the scenario has signs of a fluid volume excess.
• • Fluid Balance Within Normal LimitsThe defining characteristics of this hypothesis are stable daily weights, moist mucous membranes, intake equal to output, and no evidence of edema or dehydration. The patient in the scenario has signs of a fluid volume excess.

Question 2 of 6

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Which hypothesis would a nurse develop when generating solutions for a patient preparing to undergo a major abdominal surgery?

• • Fluid volume excessThe patient does not have a fluid volume excess now, and it is not known if the patient will return from surgery with an excess caused by excessive infusion of intravenous (IV) fluids. The assessment must be made prior to assigning this hypothesis.
• • Impaired Fluid IntakeThe patient does not have a fluid volume deficit now, and it is not known if the patient will return from surgery with a deficit. The assessment must be made prior to assigning this hypothesis.
• • Decreased cardiac outputIt is unknown if the patient has decreased cardiac output since this is based on assessment findings.
• Correct
  • Risk for fluid volume imbalanceAny patient undergoing a major surgical procedure is at risk for fluid imbalance. The nurse would prioritize assessing and reassessing the patient’s fluid volume status.

Question 3 of 6

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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 dry mucous membranes, low blood pressure, tachycardia, lethargy, and cool, pale skin. Which nursing hypothesis is appropriate?

• Correct
  • Impaired Fluid IntakeThis hypothesis addresses supporting assessment findings from the scenario.
• • Risk for fluid volume imbalanceAlthough the patient has low blood pressure, the loss of fluid volume is related to nausea and vomiting. Also, this patient is not at risk; this patient actually has Impaired Fluid Intake.
• • Impaired Skin IntegrityThese findings indicate a decrease in fluid volume. The skin assessment findings are not indicative of Impaired Skin Integrity, but Impaired Fluid Intake.
• • Activity IntoleranceEdema is not found on assessment as it is a manifestation of fluid volume excess. Lethargy and decreased urine output are not evidence of decreased activity tolerance caused by edema.

Question 4 of 6

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A patient has Impaired Fluid Intake due to decreased circulating volume observed by the nurse as low blood pressure, thready pulse, tachycardia, decreased urine output, and thirst. Which statement represents a measurable, patient-centered outcome?

• • Increase oral fluid intake.This goal is vague and not patient centered or measurable. The goal should include action-oriented items and a time frame.
• • Restore fluid balance by administering intravenous (IV) fluids as prescribed.This is not a patient-centered, measurable goal. It is important to administer IV fluids as prescribed, but this statement does not represent a specific, patient-centered goal.
• Correct
  • The patient will consume at least 100 mL of fluids every hour for a 12-hour shift.This goal is patient centered, specific, and measurable, and has a time frame. This meets all the criteria for a nursing goal.
• • The patient will have a urine output of at least 30 mL/hour.Although this is a measurable and patient centered goal, there is no defined time frame, and there is no guidance as to how this goal will be achieved.

Question 5 of 6

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A patient has fluid volume excess due to increased fluid retention, observed by the nurse as edema, decreased urine output, dyspnea, and activity intolerance. Which outcomes would be appropriate for the nurse to include when generating solutions?

• Correct
  • The patient will consume no more than 1500 mg of sodium in a 24-hour period.Reducing sodium is important to decrease edema and fluid retention. The primary health care provider may prescribe a sodium-restricted diet. The dietitian consults with the patient about the diet plan, and the nurse teaches the patient the reason for it and supports patient adherence.
• • The patient will exhibit no signs of edema or dyspnea.This goal is not specific, action oriented, or patient centered.
• Correct
  • The patient will maintain a urinary output of greater than 30 mL/hour for 24 hours.Adequate urinary output will reflect a resolution of fluid retention. This goal is patient centered, measurable, action oriented, and specific.
• • The patient will have no signs of fluid volume excess.Although this goal is patient centered and has a time frame, it is not specific and is not measurable. It is too vague.
• Correct
  • The patient will be able to walk 50 feet without dyspnea by the end of a 12-hour shift.This goal is patient centered, specific, and measurable, and has a time frame.

Question 6 of 6

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Which outcome statement is most appropriate to achieve and maintain fluid balance?

• • The patient will exhibit no skin breakdown as a result of edema during hospitalization.This patient-centered goal focuses on skin integrity related to a potential complication of edema (increased skin fragility) rather than fluid balance itself.
• Correct
  • The patient’s intake and output will be approximately equal during a 24-hour day.This patient-centered goal directly addresses the desired outcome of fluid balance.
• • The patient’s systolic blood pressure will remain between 100 and 130 mm Hg for 24 hours.This patient-centered goal focuses on measuring blood pressure, which may be appropriate based on the patient’s specific signs and symptoms; however, it does not directly address the outcome.
• • The patient will have no dryness or cracking of mucous membranes by the end of the shift.This patient-centered goal may be appropriate based on the patient’s specific signs and symptoms but does not directly address fluid balance.