Question

An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is "The client will maintain urine output of at least 30 mL/hour." Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct.

1)Measure and record urine output every hour; report an output of less than 30 mL/hour.

2)Monitor skin turgor and moistness of mucous membranes every shift.

3)Administer IV fluids as prescribed.

4)Keep oral fluids within the patient's reach, and encourage the patient to drink.

Answer 1

To maintain a urine output of at least 30 mL/hour for a dehydrated elderly patient, the nurse should measure and record urine output hourly, administer IV fluids as prescribed, and ensure oral fluids are accessible and encourage their intake.

Step-by-step explanation:

To achieve the nursing goal that "The client will maintain urine output of at least 30 mL/hour," the following nursing interventions would be helpful:

1. Measure and record urine output every hour; report an output of less than 30 mL/hour.
2. Administer IV fluids as prescribed by the physician.
3. Keep oral fluids within the patient's reach, and encourage the patient to drink

Measuring and recording urine output is a direct way to assess the effectiveness of hydration efforts and ensure that the patient is producing sufficient urine to remove metabolic wastes and maintain organ function. Administering IV fluids can rapidly rehydrate the patient, especially if they are unable to take sufficient oral fluids. Providing easy access to oral fluids and encouraging their intake can further support hydration needs.

The intervention to monitor skin turgor and moistness of mucous membranes every shift, while important for assessing dehydration levels, does not directly influence urine output and therefore is not included in the interventions listed.