After a cardiac catheterization, the client needs to increase his or her fluid intake for which reason? Show
NPO status will cause the client to be thirsty. The dye causes an osmotic diuresis. The dye contains a heavy sodium load. The pedal pulses will be more easily palpable. The dye causes an osmotic diuresis. **After a cardiac catheterization, the client needs to increase fluid intake because the dye used causes osmotic diuresis. The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment.Although the client may report thirst while NPO, the reason to increase fluids is related to osmotic diuresis from the contrast medium. The contrast medium is iodinated and does not contain a heavy sodium load. Although maintaining fluid volume may make pulses more obvious, this is not the reason to encourage fluids. A client who is suffering from dyspnea on exertion and congestive heart failure (CHF) will most likely report which symptom during the health history? Fatigue Swelling of one leg Slow heart rate Brown discoloration of lower extremities Fatigue **The CHF client with dyspnea on exertion will most likely report fatigue during the health history. Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle.Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of long-standing venous stasis, such as occurs with varicose veins. Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? "I don't know how I am going to change my lifestyle." "I don't need to change. It hasn't killed me yet." "I don't think it is as bad as the doctors say." "I will have to change my diet and exercise more." "I don't need to change. It hasn't killed me yet." **An example of maladaptive denial to a recent cardiovascular diagnosis is when the client says that change is not needed, because "it hasn't killed me yet." This type of denial is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care.Not knowing how to change indicates that the client is overwhelmed, not in denial. Not thinking it is that bad indicates denial, but not maladaptive denial. Changing diet and exercising more indicate a willingness to change. Which client has the highest risk for cardiovascular disease? Man who smokes and whose father died at 49 of myocardial infarction (MI) Woman with abdominal obesity who exercises three times per week Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL (1.94 mmol/L) Man who is sedentary and reports four episodes of strep throat Man who smokes and whose father died at 49 of myocardial infarction (MI) **The client who has the highest risk for cardiovascular disease is the man who smokes and whose father died at 49 years of age of MI. Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death.Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI, but an HDL cholesterol of 75 mg/dL (1.94 mmol/L) is in the optimal range of greater than 55 mg/dL (1.42 mmol/L). Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease. Which client would the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain Client who has many questions about the electrophysiology studies (EPS) scheduled for today Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes **The client returning from a coronary arteriogram who requires vital signs and checks of the insertion site every 15 minutes. This client is within the scope of practice of a newly licensed RN.An experienced critical care nurse is needed to assist with insertion of a pulmonary artery catheter for hemodynamic monitoring. A client with electrocardiographic changes is potentially unstable, so the experienced nurse will need to monitor the electrocardiogram, administer nitroglycerin, and identify additional interventions as needed. The experienced critical care nurse needs to provide extensive teaching about the invasive procedure of EPS. The newly licensed nurse just off orientation may not have the depth of knowledge to perform this teaching independently. Which of these factors contribute to the risk for cardiovascular disease? Consuming a diet rich in fiber Elevated C-reactive protein levels **Factors that contribute to the risk for cardiovascular disease include elevated C-reactive protein levels and smoking. Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation must also be emphasized. Smoking is a major modifiable risk factor for cardiovascular disease.A diet rich in fiber is not a risk factor for cardiovascular disease, but rather a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis. Elevated HDL cholesterol is desirable and may be cardioprotective. Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? Client with abdominal pain and belching Client with pressure in the mid-abdomen and profound diaphoresis Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows Client with claudication and fatigue Client with pressure in the mid-abdomen and profound diaphoresis **The client with pain most consistent with an MI is the client with pressure in the mid-abdomen and profound diaphoresis. Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety.Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease. A client with heart failure reports a 7.6-pound (3.4 kg) weight gain in the past week. What intervention does the nurse anticipate from the primary health care provider? Dietary consult Sodium restriction Daily weight monitoring Restricted activity Daily weight monitoring **The nurse expects that the primary health care provider will want the client's daily weights monitored. A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg), or 4 to 7 L of fluid to occur before excess fluid accumulation (edema) is apparent.The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions. The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? Right atrial pressure is 4 mm Hg. Mean arterial pressure (MAP) is 58 mm Hg. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. PO2 is reported as 78 mm Hg. Mean arterial pressure (MAP) is 58 mm Hg. **To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. An MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain.An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg. Which signs and symptoms are seen with suspected pericarditis? Squeezing, vise-like chest pain Chest pain relieved by
sitting upright **The chest pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing.Squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer. The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action would be taken by he nurse? No intervention is needed; this is a normal reading. Collaborate with the primary health care provider to administer a positive inotropic agent. Administer a STAT dose of metoprolol (Lopressor). Ask the client to perform the Valsalva maneuver. Collaborate with the primary health care provider to administer a positive inotropic agent. **A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min.No intervention is needed because this is a normal reading. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility, so cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output. The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the primary health care provider? Saline infusion Morphine sulfate No treatment, continue monitoring Intravenous furosemide Intravenous furosemide **The nurse expects that the primary health care provider will request intravenous furosemide be given to the client with a right atrial pressure of 8 mm Hg. Normal right atrial pressure is 0 to 5 mm Hg. The primary health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure.Administering saline will increase the right atrial fluid balance and pressure. Morphine is indicated to reduce preload, measured by left ventricular end-diastolic pressure or left atrial pressure. Because this is an abnormal finding, the nurse must collaborate with the provider to decrease the right atrial pressure. Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? Assess preprocedure medications the client took that day. Have the client sign the consent form before the procedure is performed. Educate the client about the need to remain on bedrest after the procedure. Obtain client vital signs and a resting electrocardiogram (ECG). Obtain client vital signs and a resting electrocardiogram (ECG). **Checking vital signs and performing a 12-lead ECG can be delegated to the UAP.The primary health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching must be done by the RN. A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and must be communicated immediately to the primary health care provider? White blood cell count Low-density lipoproteins Serum troponin I level C-reactive protein Serum troponin I level **Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications.The white blood cell count does not reflect ACS. A mild leukocytosis (increase in white blood cells) may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem. The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information would be included? Men do not tend to report chest pain. Men are more likely than women to die after MI. Men more than women tend to deny the importance of symptoms. Women may experience extreme fatigue and dizziness as sole symptoms. Women may experience extreme fatigue and dizziness as sole symptoms. **The differences in symptoms of MI in men versus women are that women may experience extreme fatigue and dizziness as sole symptoms. Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like.Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women. Which statement about diagnostic cardiovascular testing is correct? Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. The left side of the heart is catheterized first and may be the only side examined. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. **The correct statement about diagnostic cardiovascular testing is that an alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. Intravascular ultrasonography (IVUS) is performed when a flexible catheter with a miniature transducer is inserted at the distal tip to view the coronary arteries. The transducer emits sound waves, which reflect off the plaque and the arterial wall to create an image of the blood vessel. It is another option besides using the medium injection method of diagnostic cardiovascular testing.Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing and not just the left side of the heart. The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the primary health care provider by the nurse for further instructions? Calcium 8.5 mEq/L (4.25 mmol/L) Potassium 3.0 mEq/L (3.0 mmol/L) Magnesium 2.1 mEq/L (1 mmol/L) International normalized ratio (INR) of 1.0 Potassium 3.0 mEq/L (3.0 mmol/L) **The nurse needs to contact the primary health care provider when a potassium level of 3.0 mEq/L (3.0 mmol/L) is noticed on a client admitted with heart failure. Normal potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Hypokalemia may predispose to the client to dysrhythmia, especially if the client is taking digitalis preparations.A normal calcium level is 8.5 to 10.5 mEq/L (4.25 to 5 mmol/L). A normal magnesium level is 1.7 to 2.4 mEq/L (0.85 to 1.2 mmol/L). INR of 1.0 reflects a normal value. All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the primary care provider before the procedure begins? The client has had intermittent substernal chest pain for 6 months. The client develops wheezes and dyspnea after eating crab or lobster. The client reports that a previous arteriogram was negative for coronary artery disease. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate. The client develops wheezes and dyspnea after eating crab or lobster. **The most important information the nurse needs to report to the primary health care provider before a coronary arteriogram is that the client develops wheezes and dyspnea after eating crab or lobster. The contrast agent injected into the coronary arteries during the arteriogram is iodine-based. The client with a shellfish allergy is likely to have an allergic reaction to the contrast and must be medicated with an antihistamine or a steroid before the procedure.The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain. The intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time. It is appropriate to know that, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure. The pulses can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed. A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? Maintains NPO (nothing by mouth) until this resolves Calls in another nurse for a second opinion Performs a complete neurologic assessment and notifies the primary care provider Explains to the client and family that this is expected after sedation Performs a complete neurologic assessment and notifies the primary care provider **The first action the nurse must do when a client recovering from a cardiac angiography develops slurred speech is to perform a complete neurologic assessment and notify the primary health care provider. Based on the assessment finding, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness must be reported immediately for prompt intervention.Keeping the client NPO and waiting for symptoms to resolve are not appropriate. This assessment does not warrant a second opinion. Slurred speech is not expected after a cardiac angiography and sedation. Which statement reflects correct cardiac physical assessment technique? Auscultate the aortic valve in the second intercostal space at the right sternal border. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. Palpate the apical pulse over the third intercostal space in the midclavicular line. Assess for carotid bruit by auscultating over the anterior neck. Auscultate the aortic valve in the second intercostal space at the right sternal border. **The statement that shows correct cardiac physical assessment technique is to auscultate the aortic valve in the second intercostal space at the right sternal border.Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck. The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? Auscultate the client's precordium for murmurs. Teach the client about the reason for the TEE. Reassure the client that the test is painless. Validate that the client has remained NPO. Validate that the client has remained NPO. **The essential nursing action the nurse must take is to validate that the client scheduled for a TEE has remained NPO. Owing to the risk for aspiration, the client must be NPO before the procedure.It is anticipated that the client with mitral stenosis may have an audible murmur, so auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test because it is uncomfortable. An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is most appropriate for the RN to assign to the LPN/LVN? A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging A client with acute coronary syndrome who has just been admitted and needs an admission assessment A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index **The most appropriate client the RN assigns to the LPN/LVN is the client admitted with peripheral vascular disease who needs assessment of the ankle-brachial index. The scope of practice of the LPN/LVN includes taking blood pressure in the arm and lower extremity. This information will be given to the nurse for assessment.The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing client education. The LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care. The LPN/LVN may implement the plan. The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? "This is a noninvasive test performed to assess your heart rhythm." "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." "This is a painless test that is done to assess the structure of your heart using sound waves." "This test evaluates you for potentially fatal cardiac rhythms." "This test evaluates you for potentially fatal cardiac rhythms." **The most correct teaching about the purpose of EPS is when the nurse says that the test evaluates the potential for fatal cardiac rhythms. EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities.A noninvasive test to assess the heart rhythm best describes the electrocardiogram. Injection of dobutamine (Dobutrex) followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography. A client who is to undergo cardiac catheterization must be taught which essential information by the nurse? "Monitor the pulses in your feet when you get home." "Keep your affected leg straight for 2 to 6 hours." "Do not take your blood pressure medications on the day of the procedure." "Take your oral hypoglycemic with a sip of water on the morning of the procedure." "Keep your affected leg straight for 2 to 6 hours." **The client undergoing cardiac catheterization must be taught to keep the affected leg straight for 2 to 6 hours after the test. The client will remain in bed and the affected leg kept straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding.The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the primary health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure, so antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating. They are not taken when the client is NPO for procedures or surgery. Which laboratory finding is consistent with acute coronary syndrome (ACS)? Troponin 3.2 ng/mL (3.2 mcg/L) C-reactive protein 13 mg/dL (130 mg/L) Triglycerides 400 mg/dL (4.52 mmol/L) Lipoprotein-a 18 mg/dL (0.64 mcmol/L) Troponin 3.2 ng/mL (3.2 mcg/L) **Normal troponin would be less than 0.03 ng/mL (0.03 mcg/L).Normal C-reactive protein would be less than 1 mg/dL (10 mg/L). This tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides would be 35-135 mg/dL (0.40-1.50 mmol/L) for females and 40-160 mg/dL (0.45-1.81 mmol/L) for males. This tests for risk for CAD, not ACS. Normal lipoprotein-a is less than 30 mg/dL (1.07 mcmol/L). This also tests for risk for CAD, not ACS. A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction (MI)? C-reactive protein of 1 mg/dL (10 mg/L) Homocysteine level of 13 mcmol/L Creatine kinase (CK) of 125 units/L Troponin of 5.2 ng/mL (5.2 mcg/L) Troponin of 5.2 ng/mL (5.2 mcg/L) **The test results that best confirm that this client sustained a MI is a troponin of 5.2 ng/mL (5.2 mcg/L). The presence of elevated troponin indicates myocardial damage. Normal troponin would be less than 0.03 ng/mL (0.03 mcg/L).A C-reactive protein level lower than 1 mg/dL (10 mg/L) is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mcmol/L is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage. Which statement best reflects correct client education for a client with a blood pressure (BP) of 136/86 mm Hg? This blood pressure is good because it is a normal reading. This blood pressure indicates that the client has hypertension or high blood pressure. This blood pressure increases the workload of the heart; the client must consider modifying his or her lifestyle. This blood pressure seems a little low; the client must be further assessed for orthostatic hypotension. This blood pressure increases the workload of the heart; the client must consider modifying his or her lifestyle. **The statement that best reflects correct client education about a BP of 136/86 mm Hg is that this blood pressure increases the workload of the heart so I need to consider modifying my lifestyle.Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. Hypertension is defined as blood pressure greater than 140/90 mm Hg. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. Orthostatic hypotension is defined as blood pressure less than 90/60 mm Hg. Safe and effective care Assess pts for allergy to iodine based contrast media before having invasive diagnostic tests requiring an iodine based contrast agent After invasive cardiovascular dx testing, like angiography and cardiac catheterization, monitor the insertion site for bleeding and hematoma formation risk for cardiovascular disease Hyperlipidemia, hypertension, excess weight, physical inactivity, smoking, psychological stress, family history, and diabetes Reduce risk for heart disease with modifiable factors Exercise, smoking cessation, diet modification, Gender differences in CVD with women Vague symptoms: fatigue, indigestion, SOB Which nursing assessment is most important immediately following cardiac catheterization?The most important nursing action following cardiac catheterization is assessing the groin for bleeding and the leg for color, warmth (circulation) and pulse. Postcatheterization care involves monitoring vital signs every 15 minutes for an hour, then every 30 minutes for an hour or until stable.
When preparing a client for a Pericardiocentesis which position does the nurse place the client in?Position the patient in a semirecumbent position at a 30- to 45-degree angle. This position brings the heart closer to the anterior chest wall.
Which condition unrelated to cardiac disease is the major cause of right ventricular failure?Pulmonary hypertension is the commonest cause of right heart failure. Other causes are RV myocarditis, genetic cardiomyopathy, ischaemia ,as well as pericardial disease.
Which feature is the hallmark of systolic heart failure?The hallmark feature of systolic heart failure is shortness of breath, also called dyspnea. A person with early systolic heart failure might get short of breath only when exercising.
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After a cardiac catheterization a clients urinary output is 3 times the clients fluid intake
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