3632

Infiltration (IV complication)

SYMPTOMS site swelling -- edema -- coolness -- dampness -- slowed rate of infusion INTERVENTIONS discontinue -- elevation -- warm/cold compress

The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder?

"Do you have a headache or become confused?"

A nurse is reinforcing preoperative teaching with a client for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make?

"Donate autologous blood before the surgery."

A client who is postoperative asks for a drink. Her diet reads "clear liquids; advance diet as tolerated." Which response should the nurse make?

"I am going to listen to your abdomen"

A client is about to have arterial blood gases drawn, and the nurse explains what an Allen's test is. What comment shows that the client understands the nurse's explanation?

"This test is done to ensure adequate collateral circulation."

IV Complications

-phlebitis - infiltration - catheter embolus - fluid overload - cellulitis

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

1+

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)?

1.Dehydration 2.Physiological stress 3.Decreased blood volume

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include?

1. Ensure adequate oxygenation. 2. Provide assistance to prevent falls. 3. Monitor medication administration of diuretics. 4. Prevent complications during potassium administration.

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels?

1.Blood transfusions 2.Bleeding or hemorrhage 3.Ingestion of potassium in medications 4.Failure to restrict dietary potassium

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload?

1.Bounding pulse 2.Difficulty breathing 3.Presence of dependent edema 4.Neck vein distention in the upright position

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium?

1.Obtain an intravenous (IV) infusion pump. 2.Monitor urine output during administration. 3.Monitor the IV site for signs of infiltration or phlebitis. 4.Ensure that the medication is diluted in the appropriate volume of fluid. 5.Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

Which clients are most likely to be at risk for the development of third spacing?

1.The client with cirrhosis 2.The client with liver failure 3.The client with CKD

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic?

10% dextrose in water 5% dextrose in 0.9% saline 5% dextrose in 0.45% saline 5% dextrose in lactated Ringer's solution

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?

72 hours

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A client with an ileostomy

hypotonic solution

A solution that causes a cell to swell

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved?

A urine specific gravity of 1.043

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3- = metabolic alkalosis

The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn?

Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed?

Asks the athletes to take a salt tablet before football practice

The nurse is caring for a client with metabolic alkalosis. The nurse plans care knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems?

Cardiac Nervous Neuromuscular

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?

Changes in mental status

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first?

Contact the primary health care provider (PHCP)

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38 (7.38), Paco2 of 38 mm Hg (38 mm Hg), Pao2 of 86 mm Hg (86 mm Hg), and HCO3 of 23 mEq/L (23 mmol/L). What action should the nurse take in response to these results?

Continue monitoring the client (NORMAL)

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?

Daily weight

The nurse is administering a dose of triamterene to an assigned client. What is the most significant adverse effect of this medication for which the client should be monitored?

HYPERkalemia

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? Metabolic acidosis

HYPOkalemia

respiratory alkalosis causes

HYPOkalemia nausea vomiting diarrhea

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

HYPOventilation Headache restlessness confusion

Fluid volume excess (HYPERvolemia)

Hct (L) Serum osmolarity (L) Urine specific gravity (L) Electrolytes (L) BUN (L) Creatinine (L)

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?

Heparin

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

Integumentary output

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Lightheadedness paresthesias

The nurse is caring for a client whose magnesium level is 3.5 (H) mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? HYPERmagnesemia

Loss of deep tendon reflexes neurological depression respiratory insufficiency drowsiness lethargy bradycardia hypotension.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Metabolic alkalosis

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?

Muscle weakness

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

Potassium level of 3.0 mEq/L (3.0 mmol/L)

The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value should the nurse expect to note?

Potassium level of 5.2 mEq/L

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate?

Pour the aspirate into the NG tube through a syringe with the plunger removed.

A client has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action?

Remove the nasal cannula for 15 minutes; then have the ABG samples drawn.

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

Requires nasogastric suction

pH = 7.30 (L) PaCO2 = 58 (H) PaO2 = 80 (N) HCO3 = 27 (H)

Respiratory acidosis

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Respiratory acidosis from inadequate ventilation (hypoventilation)

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition?

Respiratory acidosis, uncompensated

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53 (H) PaO2 = 72 (L) HCO3 = 28 (H) Which conclusion about the client should the nurse make?

Respiratory alkalosis The client is probably hyperventilating.

The nurse reviews the arterial blood gas results of a client and notes the following: pH = 7.45 (H) = alkalosis, compensated PCO2 = 30 (L) = opposites HCO3 = 20(L)

Respiratory alkalosis, compensated

Cellulitis (IV coomplication)

SYMPTOMS pain -- warmth -- edema -- induration -- red streak -- fever -- chills -- malaise INTERVENTIONS stop infusion -- remove IV -- elevate extremity -- warm compresses -- obtain a specimen for culture -- administer medications as ordered

The nurse reviews a client's arterial blood gas values and notes a pH of 7.50 (H) (7.50), a PaCO2 of 30 (L) mm Hg (30 mm Hg), and an HCO3 of 25 (N) mEq/L (25 mmol/L). The nurse should interpret these values as an indication of which condition?

Respiratory alkalosis, uncompensated

Catheter embolus (IV complication)

SYMPTOMS - missing catheter tip when removing IV - severe pain with migration INTERVENTIONS - place tourniquet high on extremity - prepare for x-ray and surgery to remove the tip

Phlebitis (IV complication)

SYMPTOMS erythema -- pain -- warmth -- edema -- indurated or cordlike veins -- red streak INTERVENTIONS discontinue -- elevate extremity -- warm compresses --obtain a specimen for culture if indicated

Fluid overload (IV complication)

SYMPTOMS increased BP -- JVD -- tachycardia SOB -- crackles -- edema INTERVENTIONS stop infusion -- raise HOB -- monitor O2 -- decrease infusion rate & administer diuretics

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

Start an IV of normal saline as prescribed.

A registered nurse (RN) has instructed an assistive personnel (AP) to administer soap suds enemas until clear to a client. The AP reports that 3 enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the AP to do?

Stop administering the enemas until the primary health care provider (PHCP) is notified.

Fluid volume excess (HYPERvolemia) symptoms

Tachycardia/ tachypnea HYPERtension Bounding pulses JVD Crackles Edema

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53 (H) = alkalosis Pao2 = 72 (L) = opposites = respiratory PaCO2 = 32 HCO3- = 28 Which conclusion about the client should the nurse make?

The client is probably hyperventilating (respiratory alkalosis)

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

The client who is taking diuretics

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

The client with kidney disease and a 12-year history of diabetes mellitus

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur?

The client's arterial blood gas results will reflect acidosis.

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Twitching

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?

Urine specific gravity of 1.032

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

Weakness and decreased central venous pressure (CVP)

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

Weight loss and poor skin turgor

hypertonic solution

a solution that causes a cell to shrink

Acute Confusion (Nursing Dx)

abrupt onset of transient changes in: - attention - cognition - psychomotor activity - sleep-wake cycle

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem?

administer prescribed antibiotics

The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?

apply a warm compress

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities (dysrhythmias)

Which client would be a candidate for total parenteral nutrition?

client with colitis and bloody diarrhea

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

decreased potassium

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client should expect to note which signs/symptoms?

decreased respiratory rate and depth

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 (L) mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client?

monitor the client for dysrhythmias

respiratory alkalosis symptoms

dysrhythmias nausea confusion tachycardia lightheadedness HYPERkalemia

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status should avoid which action?

encouraging the client to breathe slowly and shallowly

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH?

fall

A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?

flush the IV with 3 mL of normal saline

A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding?

hematuria facial flushing fever back pain

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?

hemolytic transfusion reaction: incompatibility of blood product

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

hyperactive bowel sounds

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

hypotonic solution

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?

infants

A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care knowing that what reaction is the most powerful regulator of acid-base balance?

kidney

A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see?

lethargy headache weakness confusion

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?

maintenance of cell size

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?

malnutrtion

A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care knowing that the client is at risk for the development of which type of acid-base imbalance?

metabolic acidosis

A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder?

metabolic acidosis

The nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul's respirations. The nurse knows that the purpose of this type of breathing is to correct what imbalance?

metabolic acidosis

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

metabolic alkalosis

The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50 (7.50), Pao2 of 90 mm Hg (90 mm Hg), Paco2 of 40 mm Hg (40 mm Hg), and bicarbonate of 35 mEq/L (35 mmol/L). When the nurse notifies the primary health care provider about these levels, the nurse should anticipate receiving from the PHCP which prescription for this client?

metabolic alkalosis - discontinue NG suctioning

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?

muscle cramping tetany

metabolic alkalosis

nausea vomiting RR low hypoventilating tachycardia HR high

HYPERmagnesemia

neurological depression: respiratory depression drowsiness sedation lethargy muscle weakness areflexia

respiratory alkalosis

pH (H) PaCO2 (L)

metabolic alkalosis

pH (H) HCO3 (H)

metabolic acidosis

pH (L) HCO3 (L)

respiratory acidosis

pH (L) PaCO2 (H)

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25 (L) Paco2 50 (H)

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH = 7.25 (L) = acidosis PaCO2 = 50 (H) opposite = respiratory

A nurse is assessing the pH of a client's gastric fluid to confirm placement of the NG tube in the stomach. Which of the following pH values should the nurse expect?

pH of 2

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?

potassium

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water?

prior & after each medication after multiple medications

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 (L) mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? HYPOcalcemia

prolonged bed rest vitamin D deficiency HYPOparathyroidism diarrhea

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder?

provide emotional support and reassurance

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?

renal system retains more water

HYPOventilation

respiratory acidosis

The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance?

respiratory acidosis

The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31 (7.31), Paco2 is 50 mm Hg (50 mm Hg), and the bicarbonate (HCO3) level is 26 mEq/L (26 mmol/L). The nurse concludes that which acid-base disturbance is present in this client?

respiratory acidosis

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30 (7.30), a PaCO2 of 58 mm Hg (58 mm Hg), a Pao2 of 80 mm Hg (80 mm Hg), and an HCO3 of 26 mEq/L (26 mmol/L). The nurse should interpret this to mean that the client has which acid-base disturbance?

respiratory acidosis

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance?c

respiratory acidosis

pH = 7.12 (L) PaCO2 = 90 (H) HCO3 = 22

respiratory acidosis, uncompensated or without compensation

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH = 7.12 (L) = acidosis PaCO2 = 90 (H) = opposites = respiratory HCO3- = 22 (N) = uncompensated The nurse interprets the results as indicating which condition?

respiratory acidosis, without compensation

Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance?

respiratory alkalosis

HYPERventilation

respiratory alkalosis

pH = 7.5 (H) alkalosis PaCO2 = 32 (L) opposites = respiratory HCO3 = 24

respiratory alkalosis

pH = 7.50 (H) = alkalosis PaCO2 = 30 (L) opposite = respiratory

respiratory alkalosis

pH = 7.53 (H) PaO2 = 72 (L) HCO3 = 28 (H)

respiratory alkalosis

The nurse reviews the arterial blood gas results of a client and notes the following: pH = 7.45 (H) = alkalosis Paco2 = 30 (L) = opposite = respiratory HCO3- = 20 (L) = uncompensated The nurse analyzes these results as indicating which condition?

respiratory alkalosis, uncompensated

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 (H) mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client? HYPERmagnesemia

respiratory depression

The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution?

seizure precautions

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 (L) mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation? HYPOnatremia

sodium chloride

The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see?

tetany tingling numbness restlessness

Which client is at risk for the development of a potassium level of 5.5 mEq/L (High)

traumatic burn sepsis metabolic acidosis respiratory acidosis

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

twitching/muscle spasms numbness/tingling + Chvostek's sign + Trousseau's sign

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?

weak peripheral pulse (thready)

Fluid volume excess (HYPERvolemia) nursing interventions

weigh daily restrict fluid & sodium administer O2 & diuretics prevent skin breakdown

A nurse is contributing to the plan of care for a client who has fluid volume excess. Which interventions should the nurse plan to include to monitor the client's weight?

weight in the morning