Question

The patient's output is 2025 mL during your 12-hour shift. If the patient had an intake of 3394 mL, what should you monitor the patient for as the nurse?

A. Fluid volume overload
B. Dehydration
C. These findings are within normal limits.
D. Continue to monitor.

Answer 1

The nurse should monitor the patient for signs of fluid volume overload, given the positive fluid balance and higher intake than output. It's also important to continue regular monitoring for any changes in the patient's fluid status.

Step-by-step explanation:

The question involves calculating and assessing a patient's fluid balance during a 12-hour nursing shift, an important aspect of patient care. Monitoring fluid intake and output is crucial for determining the patient's hydration status and ensuring proper renal function. According to the information provided, the average adult takes in and loses about 2500 mL of water per day. Given that the patient's intake was 3394 mL and the output was 2025 mL, the patient had a positive fluid balance of 1369 mL during the 12-hour shift. Normal urine output should align with intake to maintain a balanced state.

Since the patient has a higher intake than output, the nurse should monitor the patient for signs of fluid volume overload. However, it is also important to continue to monitor the patient, as changes in fluid volume can occur rapidly and need careful ongoing assessment. Indications of fluid volume overload may include edema, an increase in blood pressure, and signs of respiratory distress.