A nurse is caring for a client who has been receiving intravenous fluids for dehydration. During the shift, the client’s oral intake is recorded at 500 mL, and their urinary output is 200 mL. Which action should the nurse take first?
Take another urinary output measurement at the next scheduled time
Decrease the intravenous fluid rate to reduce fluid intake
Document findings and report them to the next shift nurse for follow-up
Evaluate for other symptoms of fluid retention or deficit (e.g., edema, hypotension, respiratory changes)
The nurse should assess for other signs of fluid imbalance, such as weight changes, edema, or decreased blood pressure, to confirm fluid retention or a developing issue. Reduced urinary output in combination with IV fluid administration could indicate renal impairment, fluid overload, or improper hydration status. Simply waiting or taking another measurement without additional evaluation may delay identifying a potentially critical issue. Documenting without taking initial further action does not address the client’s immediate needs.
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NCLEX RN
Physiological Integrity
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