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
Chest physiotherapy can help loosen secretions that may not be audible with a stethoscope. This can help improve the patient’s breathing and overall lung function.
Correct Answer is D
Explanation
Atrial fibrillation is a common arrhythmia, and diuretics are often used in the management of patients with this condition to help control fluid balance. However, diuretics can cause electrolyte imbalances, especially hypokalaemia (low potassium levels), which can lead to muscle cramps and other complications.
A Complete Metabolic Panel (CMP) is a blood test that measures various electrolytes, glucose, and other important components. Among the options given, the most likely lab value to be abnormal in Patient MK's case is a low level of potassium (K+), which is consistent with her symptoms and diuretic use. Option d, K+ -
-
- mEq/L, is the correct option as it represents a low level of potassium, which is defined as a value less than 3.5 mEq/L.
Option a, Mg2 – 20 mEq/L, represents high magnesium levels, which are not typically associated with diuretic use or muscle cramps. Option b, Na+ - 123 mEq/L, represents low sodium levels, which are less likely to occur with diuretic use, and are typically associated with other conditions. Option c, Ca2 – 10.0 mg/dl, represents normal calcium levels and is not typically affected by diuretic use.
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