Fundamentals Question #11

Question

The client’s intake is 2160 mL and the output is 1230 mL during a 12 hour shift. What should the nurse monitor for?

Answers

  1. Fluid volume overload
    • Rationale:

      This answer is correct because the total intake from this scenario is 2160 mL and the total output is 1230 mL in a 12 hour shift. This indicates more fluid has been taken in that has left the body, or fluid volume overload. Symptoms of fluid volume overload include crackles in the lung fields, edema, jugular vein distention, and intake significantly different from the output. These symptoms and findings should be reported to the healthcare provider.

  2. Fluid volume deficit
    • Rationale:

      This answer is not correct because the total intake from this scenario is 2160 mL and the total output is 1230 mL in a 12 hour shift. This indicates more fluid has been taken in that has left the body, or fluid volume overload (not fluid volume deficit). Symptoms of fluid volume overload include crackles in the lung fields, edema, jugular vein distention, and intake significantly different from the output. These symptoms and findings should be reported to the healthcare provider.

  3. Dehydration
    • Rationale:

      This answer is not correct because the nurse should monitor for fluid volume overload, not dehydration. An intake of 2160 mL and an output of 1230 mL during a 12 hour shift indicates fluid volume overload. Symptoms of fluid volume overload include crackles in the lung fields, edema, jugular vein distention, and intake significantly different from the output. These symptoms and findings should be reported to the healthcare provider.

  4. Renal failure
    • Rationale:

      This answer is not correct because there is no evidence that the client is in renal failure since an output of 1230 mL was measured. An intake of 2160 mL and an output of 1230 mL during a 12 hour shift indicates fluid volume overload.

Overview

An intake of 2160 mL and an output of 1230 mL during a 12 hour shift indicates fluid volume overload.

Explanation

Learning Outcomes

Correct calculation of intake and output is an important responsibility of the nurse. The total intake from this scenario is 2160 mL and the total output is 1230 mL in a 12 hour shift. This indicates more fluid has been taken in that has left the body, or fluid volume overload. Symptoms of fluid volume overload include crackles in the lung fields, edema, jugular vein distention, and intake significantly different from the output. These symptoms and findings should be reported to the healthcare provider. The nurse should inquire further regarding this, unless this is an expected finding due to dehydration fluid replacement therapy. If this is due to fluid replacement, the client will not have the other assessment findings besides intake significantly higher than output.

Test Taking Tip

Read the question and consider what is given in the scenario and what is not given. If trying to determine what is going on with the client, watch for if the client is urinating, then the client does not have renal failure. If there is a great deal of intake compared to output, the nurse does not have to monitor for dehydration. If there is more fluid going in that is leaving the body, then there is not a risk of fluid deficit. Let the question’s information given direct you.

Video Rationale