(dry, salty, or sweet foods or fluids). The nurse could
then work with the patient to develop short-term
outcomes for accomplishing the overall task and
discuss with the patient the time intervals at which
fluids will be served. Fluids could be served in small
cups to make the cup appear to contain more liquid
and ice chips could be offered at intervals. The
nurse should provide oral hygiene at regular inter-
vals so that the patient’s mouth remains clean and
moist and lubricate the lips and mucous
membranes as indicated.
2.What would be a successful outcome for Mr. Park?
By end of shift, Mr. Park lists the reasons for fluid
restrictions and states that he is breathing more eas-
ily following implementation of treatment regimen.
3.What intellectual, technical, interpersonal, and/or
ethical/legal competencies are most likely to bring
about the desired outcome?
Intellectual: knowledge of how to promote and
maintain fluid, electrolyte, and acid–base balance
Technical: ability to use the equipment and proto-
cols necessary to maintain and restore fluid,
electrolyte, and acid–base balance
Ethical/Legal: strong sense of accountability for the
health and well-being of patients and willingness to
hold colleagues accountable for safe quality practice
4.What resources might be helpful for Mr. Park?
Patient teaching plan, printed materials on overhy-
dration
PATIENT CARE STUDY
1.Objective data are underlined; subjective data are in
boldface.
Rebecca is a college freshmanwho had her wisdom
teeth removed yesterday morning. She had a sore
throat several days before the extraction but did not
mention this to the oral surgeon. Because of her
sore throat, she had greatly decreased both her
food and fluid intake.The night of the surgery,
she had an oral temperature of 39.5C (103.1F).
Friends gave her some Tylenol, which brought her
temperature down, and encouraged her to drink
more fluids. When they checked on her this morn-
ing, her temperature was elevated again,and she
said she had felt too weak during the night to
drink.They took her to the student health service,
where the admitting nurse noticed her dry mucous
membranes, decreased skin turgor, and rapid pulse.
At 5 feet 2 inches and 98 pounds, Rebecca had lost
4 pounds in the past week.
2.Nursing Process Worksheet
Health Problem: Fluid volume deficit
Etiology: Decreased fluid intake (sore throat and
weakness) and loss of water and electrolytes in fever
Signs and Symptoms: Elevated temperature (39.5C),
4-lb weight loss in 1 week, dry mucous membranes,
decreased skin turgor, and rapid pulse
Expected Outcome: By 3/19/11, patient will demon-
strate corrected fluid volume deficit by (1) balanced
fluid intake and output, averaging 2,500 mLfluid/day; (2) urine specific gravity within normal
range (1.010 to 1.025); (3) moist mucous
membranes and adequate skin turgor; and (4) pulse
returned to baseline.
Nursing Interventions:
a.Assess for worsening of fluid volume deficit.
b.Give oral fluids that are nonirritating, as
tolerated.
c. If oral fluids are not tolerated, confer with MD
regarding IV replacement therapy.
d.Monitor response to fluid therapy: vital signs, urine
volume and specific gravity, increased skin turgor,
moist mucous membranes, increased body weight.
Evaluative Statement: 3/19/11: Goals met—patient
has corrected fluid volume deficit; fluid intake and
output average 2,700 mL fluid/day; pulse returned
to baseline; skin turgor improved; mucous
membranes are moist.—J. Barclay, RN
3.Patient strengths: Previously healthy; concerned
friends; highly motivated to correct deficit
Personal strengths: Strong knowledge of fluid, elec-
trolyte, and acid–base balance; good interpersonal
skills
4.3/19/11: Patient tolerating oral replacement fluids
and understands importance of increasing fluids
until the deficit is corrected. Friends remind her to
drink at frequent intervals. Pulse returned to
baseline. Yesterday’s fluid intake was 2,900 mL fluid,
output 2,500 mL. Improved skin turgor and moist
mucous membranes. Gained 2 lb.—J. Barclay, RNCHAPTER 41
PRACTICING FOR NCLEX
MULTIPLE CHOICE QUESTIONS
1.b 2.a 3.b 4.c 5.d
6.c 7.c 8.a 9.a
ALTERNATE-FORMAT QUESTIONS
Multiple Response Questions
1.b, c, f
2.a, d, e
3.a, b, dDEVELOPING YOUR KNOWLEDGE BASE
FILL-IN-THE-BLANKS
1.Self-actualization
2.Self-concept
3.Global self
4.Ideal self
5.False self
6.Personal identity
MATCHING EXERCISES
1.a 2.d 3.h 4.e 5.f
6.c 7.g 8.d 9.b 10.c
11.a 12.d 13.b 14.c 15.d
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