NCLEX Review

1. Which blood lab values would the

nurse be most concerned about for an
adult patient?
a. BUN 19 mg/dL
b. K 2.8 mEq/L
c. Creatinine 19 mg/kg/24hr
d. CO2 24 mmol/L
2. What level of 24 hour urine output
would lead the nurse to call the physician?
a. 1000ml
b. 800ml
c. 1200ml
d. 700ml
3. A patient recovering from dehydration
is on a diuretic. Which items should be
included in a nutrition plan to reduce risk
of future dehydration?
a. Orange juice
b. Banana
c. Both a and b
d. Neither a and b

References
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Campbell, N. (2014). Rcognising and preventing dehydration
among patients. Nursing Times, 110(46), 20-21.
Davidson, T., Culvert, L., & Frey, R. (2011). Dehydration. In L.
J. Fundukian (Ed.), Gale Encyclopedia of Medicine, Vol.
2. (4th ed.). Detroit: Gale. Retrieved February 26,
2015, from NRCX via Gale:
http://0-find.galegroup.com.libcat.ferris.edu/nrcx/
start.do?prodId=NRC
Doenges, M., & Moorhouse, M. (2013). Nurse's pocket guide:
Diagnoses, prioritized interventions, and rationales (Ed.
13. ed.). Philadelphia, PA: F.A. Davis. Retrieved
February 24, 2015 from
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Document.aspx?
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(n.d.). Retrieved February 24, 2015, from http://
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Drinking Water, Water, Food, Drip - Free Image on Pixabay.
(n.d.). Retrieved February 26, 2015, from http://
pixabay.com/en/drinking-water-water-food-drip-597001/
Pash E, Parikh N, Hashemi L. Economic burden associated with
hospital postadmission dehydration. JPEN Journal Of
Parenteral & Enteral Nutrition [serial online]. November
2, 2014;38(2):58S-64s. Available from: CINAHL, Ips
wich, MA. Accessed February 27, 2015.
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water-glass-pouring-drinking-water-295062/

DEHYDRATION
Nursing Evidence Based Practice Review

Dehydration occurs when the body does

not have enough water and fluid as it
needs to function well. Up to 20% of
inpatients become dehydrated while in
the hospital. If dehydration progresses
beyond just a water and sodium imbalance serious complications can occur if
the lost fluid does not get replaced
(Broad, 2013).

BY DAPHNE FITZPATRICK

Ferris State University

College of Health Professions
School of Nursing

Risk Factors

Signs and Symptoms

Nursing Considerations

Mild Dehydration
Dark concentrated urine
Dry mucous membranes
Increased thirst, cracked lips
Lethargy, confusion
Dizziness
Acute Dehydration
Increased weak heartrate
Decreased serum potassium
Low systolic BP <100mmHg
Slow capillary refill
Cold extremities
Increased respiration
Reduced level of consciousness
*s/s (Campbell, 2014) and (Davidson, 2011)

Treatment

Fever, sweating from heat, activity

Fluid loss from vomit, diarrhea (bacteria, virus,
parasites)
Chronic conditions such as: diabetes, kidney
disease, alcoholism, malnutrition,
Not drinking enough
Patients with severe burns
Certain medications, such as diuretics.
Most at risk are young children and elderly due
to being more susceptible to diseases that lead
to fluid loss from vomiting and diarrhea.

Nursing Diagnoses

Decreased skin turgor and dry mucous

membranes related to fluid loss from diarrhea
and vomiting.
Fluid volume deficit related to inadequate water
intake.
Fluid and electrolyte deficit related to diuretic
use.
Isotonic dehydration is the most common type,
caused by a loss of both water and sodium equally.
Vomiting and diarrhea are common factors, fluid
between the ICF and ECF are still balanced.
Hypertonic dehydration is when more water is lost
than sodium. Too little water intake or long term
fever are reasons for this type, which has a higher
mortality rate.
Hypotonic dehydration is when the more sodium is
lost than water. This is caused by diuretics and also
depletes potassium levels can be counteracted by
educating patient to ingest foods that have good
supply of potassium in their daily intake (Davidson,
2011).

Monitoring fluid intake, and output.,

including baby and adult diapers.

Encourage caffeine avoidance.

Check for a minimum output of 30ml/

hr/24hrs.

For mild to moderate dehydration: Children

should sip 15ml every 20 minutes, 30ml if
over one year of age. Breastfed babies
should receive two clear feedings before
restarting breast-milk and bottle-fed should
have diluted formula at half strength. Sports
drinks or rehydration solutions are good for
older children and adults should do well
with water (Davidson,2011).

Assessing for physical symptoms, vitals, lab

values.

Check medication and nutrition plan and

communicate with physician and patient.

For serious dehydration IV fluids may be

required.

Desired Outcomes & Evaluation Criteria

Patient will achieve and maintain a stable

and adequate fluid balance.
Patient will have good vital signs, intake
and output, moist mucous membranes,
and skin turgor reflective of fluid and
electrolyte balance.
Patient communicates an understanding
of maintaining hydration and preventing
future episodes by understanding the
causes and symptoms of dehydration
(Campbell, 2014).