What is the primary nursing intervention for a patient receiving 3% saline as maintenance fluids?

The primary nursing intervention for a patient receiving 3% saline as maintenance fluids is to assess blood pressure. This is crucial due to the hypertonic nature of 3% saline, which can lead to rapid fluid shifts and potential complications such as hypernatremia and fluid overload. Monitoring blood pressure helps detect these changes early, ensuring timely intervention if the patient starts to experience adverse effects such as hypertension due to increased fluid volume or hypotension from potential fluid shifts.

Monitoring urine sodium can provide information about kidney function and sodium status, but it is not the primary intervention in this context. Keeping track of serum electrolytes is also essential, especially sodium levels, to avoid complications associated with excessive sodium administration. However, it is more of a supportive measure rather than the immediate focus in terms of patient safety. Collecting a 24-hour urine output is important in assessing kidney function but is often not as immediately critical as monitoring blood pressure in the context of administering hypertonic saline solutions. Assessing blood pressure allows for real-time adjustments to the care plan and ensures patient stability, making it the top priority.