A nurse on the medical surgical floor is preparing a nursing care plan for a patient with acute renal failure. The patient has oliguria with fluid volume excess. The nurse should include which of the following interventions in the care plan?

Maintain accurate documentation of strict intake and output daily.


•An important nursing intervention is to accurately record and monitor the patient's daily intake and output of fluids.

Incorrect options:

•A patient with fluid volume excess will require daily measuring and recording of weight to monitor if the fluid volume excess is decreasing in response to interventions, not just at admission and discharge.

•Patients with fluid volume excess are usually placed on a po fluid intake restriction, so encouraging increased po fluid intake is not appropriate.

•Intravenous fluid intake must be included in the overall intake and output totals that are documented daily, but decreasing intravenous fluid intake must be managed with collaboration with the doctor and not done by the nurse without doctor's orders.

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