A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.
Explanation & Rationale
A. Calculate the intake and output: Measuring intake and output directly reflects fluid balance, making it one of the most reliable ways to determine if fluid restriction and diuretics are effective. Tracking fluid intake compared to urine output helps assess reduction in fluid overload. B. Assess pulse rate: While monitoring pulse rate is part of routine assessment, it does not provide a clear picture of whether fluid overload is improving. Changes in pulse may occur with dehydration, arrhythmias, or other conditions, but it is not a primary measure of fluid balance. C. Monitor the temperature: Body temperature is important for identifying infection or inflammation but does not indicate fluid status. Monitoring temperature would not help evaluate whether fluid restriction and diuretic therapy are relieving fluid overload. D. Checking for orthostatic hypotension: Orthostatic changes can suggest hypovolemia or dehydration but are less useful for measuring the gradual effectiveness of fluid restriction. They may be monitored if over-diuresis is suspected, but they are not the best evaluation tool. E. Obtain a daily weight: Daily weight is one of the most accurate indicators of fluid balance. A decrease in weight reflects effective removal of excess fluid, as even small weight changes can indicate significant fluid gain or loss in the body.