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
. 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.
Correct Answer is A
Explanation
Difficulty breathing is a sign of a potential transfusion reaction. When a client reports difficulty breathing during a blood transfusion, the nurse should stop the transfusion immediately to prevent the reaction from worsening. Once the transfusion is stopped, the nurse can then assess the client's vital signs and notify the healthcare provider of the client's response. Documentation of the findings should also be completed after the client's condition has stabilized. However, stopping the transfusion takes priority over documenting the findings.
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