At the end of shift, you are calculating intake and output on your pat lent who was admited for a non- emergent gall bladder removal. She is alert and oriented and able to recall the amount of fluid she has drank all day. You can calculate the amount of IV fluids administered. Her intake is 2500ml and her output is 1200ml from a catheter bag. You realize she is not excreting enough urine me for water she is taking in. What is the most appropriate next step to determine if she is retaining water?
Put a hat in the toilet to collect proper output.
Assess your patient’s lower extremities and lungs for fluid retention.
Educate her on the importance of writing down all fluids she is drinking.
Document the numbers anyway, there is a probable error with the intake number.
The Correct Answer is B
. Assess your patient’s lower extremities and lungs for fluid retention.
If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for fluid retention. This can help determine if the patient is retaining water and if further intervention is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
: A client with renal disease may have impaired kidney function, which can affect fluid balance in the body. Giving fluids too quickly or increasing the infusion rate too quickly can lead to fluid overload,
which can exacerbate the client's condition. It is important for the nurse to monitor the amount of fluid the client is receiving to ensure that the infusion rate is appropriate for the client's condition and to prevent fluid overload. Checking the intravenous rate every two days is not sufficient; the nurse should monitor the rate regularly and adjust it as necessary based on the client's response.
Correct Answer is B
Explanation
Renal failure can cause a buildup of fluid in the body. When kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood’s chemical makeup may get out of balance. This can lead to fluid retention, causing swelling in your legs, ankles or feet.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today