Which nursing intervention ensures the most accurate monitoring of the client's fluid status that client is at risk for excess fluid volume?
Change Image Delete
A. Measuring and recording fluid intake and output B. Weighing the client daily at the same time each day C. Assessing the client s vital signs every 4 hours D. Checking the client s lungs for crackles during every shift
Weighing the client daily at the same time each day-rationale: increased fluid volume leads to rapid weight gain 2.2 lb (1 kg) for each liter of fluid retained. weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. the nurse should plan to detect fluid accumulation before pulmonary edema occurs.client needs category: physiological integrityclient needs subcategory: reduction of risk potentialcognitive level: applicationreference: smeltzer, s.c., and bare, b. brunner & suddarths textbook of medical surgical-nursing, 11th ed. philadelphia: lippincott williams & wilkins, 2008, p. 957.