A nurse is monitoring the urinary output of a client who had a colon resection. Which 24-hour output total indicates oliguria?
380 mL
550 mL
600 mL
720 mL
The Correct Answer is A
Choice A Reason:
A 24-hour urinary output of 380 mL indicates oliguria. Oliguria is defined as a urine output of less than 400-500 mL per day in adults. This condition can be caused by various factors, including dehydration, kidney dysfunction, or postoperative complications. Monitoring urine output is crucial for assessing kidney function and overall fluid balance, especially after major surgeries like a colon resection.
Choice B Reason:
A 24-hour urinary output of 550 mL is slightly above the threshold for oliguria. While it is still relatively low, it does not meet the strict criteria for oliguria, which is typically defined as less than 400-500 mL per day. This output suggests that the client is producing an adequate amount of urine, though it may still warrant close monitoring to ensure it does not decrease further.
Choice C Reason:
A 24-hour urinary output of 600 mL is within the normal range and does not indicate oliguria. Normal urine output for adults is generally considered to be around 800-2000 mL per day, depending on fluid intake and other factors. This output suggests that the client’s kidneys are functioning properly and that there is no immediate concern for oliguria.
Choice D Reason:
A 24-hour urinary output of 720 mL is also within the normal range and does not indicate oliguria. This output is closer to the lower end of the normal range but still suggests adequate kidney function. It is important to continue monitoring the client’s urine output to ensure it remains within a healthy range, especially after surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Lubricate the suction catheter tip with sterile saline is important to ensure smooth insertion and reduce trauma to the tracheal mucosa. However, this is not the first step. Preoxygenation is crucial to prevent hypoxia during the suctioning process.
Choice B Reason:
Perform chest physiotherapy prior to suctioning can help mobilize secretions, making them easier to remove. While beneficial, it is not the immediate first step. Ensuring the client is adequately oxygenated takes precedence.
Choice C Reason:
Hyperventilate the client on 100% oxygen prior to suctioning is correct. This step is essential to prevent hypoxia during suctioning. Suctioning can temporarily reduce oxygen levels, so preoxygenating the client helps maintain adequate oxygenation throughout the procedure.
Choice D Reason:
Suction two to three times with a 60-second pause between passes is a recommended practice to allow the client to recover between suctioning attempts. However, this step follows the initial preoxygenation.
Correct Answer is A
Explanation
Choice A Reason:
Cranial nerve V is the trigeminal nerve, which has both motor and sensory functions:Motor function: The nurse can assess this by asking the client to clench their teeth while palpating the masseter and temporalis muscles for strength.Sensory function: The nurse can assess this by lightly touching the client's face in different areas (forehead, cheeks, and jaw) with a cotton ball or sharp/dull object to check for sensation.
Choice B Reason:
Asking the client to identify scented aromas is a method used to assess cranial nerve I (Olfactory), not cranial nerve V. Cranial nerve V (Trigeminal) is assessed by testing facial sensation and motor functions such as chewing.
Choice C Reason:
Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V
Choice D Reason:
Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.
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