The nurse established the following objective for the client who was u

The nurse established the following objective for the client who was unable to void: The client’s intake will be at least 1000 mL between 7 AM and 3:30 PM. Feedback showing success is indi-cated by the client:

1. Voiding at least 1000 mL during the shift
2. Verbalizing abdominal comfort without pressure
3. Having adequate fluid intake and urinary output
4. Drinking 240 mL of fluid five or six times during the shift

ANSWER

ANS: 4
The nurse evaluates success by observing the client’s performance of each expected behavior. Feedback indicating success in this situation is the client drinking 240 mL of fluid five or six times during the shift. This would be a fluid intake of 1200-1440 mL, meeting the objective of at least 1000 mL during the designated time period. Voiding at least 1000 mL is not the objective. The objective is to have the client drink at least 1000 mL. Verbalizing abdominal comfort with-out pressure is not an evaluation of the objective regarding specific fluid intake. Having adequate intake and output is not accurate feedback indicating success. The term adequate is not quanti-fied.