NCLEX-PN

Intake ●​ Solid Intake : Monitor and measure the consumption of solid foods in terms of ounces. ●​ Liquid Intake : Monitor and measure fluid intake in milliliters (mL) ●​ Tube Feedings : Include the volume of nutritional supplements or tube feedings. ●​ Intravenous Fluids : Consider the volume of fluids administered intravenously. Output ●​ Urinary Output : Measure urinary elimination in mL for adults and through diaper weights or counts for neonates and infants. An hourly urinary output of less than 30 mL is considered abnormal. ●​ Stool Output : Monitor bowel movements in terms of frequency and consistency. Measure liquid stools and diarrhea in mL. ●​ Vomitus : Measure the volume of vomit in mL. ●​ Other Outputs : Include measurements of wound drainage, ostomy output, and other relevant fluid losses. Indirect Evidence and Assessment ●​ Vital Signs : Observe changes in blood pressure, heart rate, and respiratory rate that may indicate fluid imbalances. ●​ Signs and Symptoms : Monitor for signs of fluid excesses (edema, hypertension) and deficits (dry skin and mucous membranes, hypotension). ●​ Weight Changes : Track short-term weight gain or loss as it may reflect fluid shifts. ●​ Laboratory Values : Consider blood tests such as electrolyte levels and hematocrit to assess fluid status. ●​ Physical Signs : Assess for poor skin turgor, sunken eyes, and orthostatic hypotension. Interventions ●​ Hydration Management : Encourage increased fluid intake when necessary or restrict fluids based on medical orders. ●​ Nutritional Adjustments : Modify oral, tube, or intravenous nutrition as needed. ●​ Fluid Replacement : Administer intravenous fluids to address deficits or losses. ●​ Fluid Removal : Implement interventions to address excess fluid accumulation, such as diuretics or specific therapies for underlying conditions.

371

© 2025 ACHIEVE ULTIMATE CREDIT-BY-EXAM GUIDE | NCLEX-PN ​

​

​

​

​