What is the priority outcome for a patient with the nursing diagnosis of fluid volume deficit related to ongoing postoperative bleeding?
The patient’s temperature will remain within normal limits.
The patient’s surgical incision will remain intact with sutures.
The patient will verbalize measures to reduce fluid volume loss.
The patient’s urine output will be at least 30 mL/hour.
The Correct Answer is D
Rationale for Choice A:
While maintaining normal body temperature is important for overall health, it's not the most immediate priority in a patient with fluid volume deficit due to ongoing bleeding. Fluid volume status takes precedence over temperature regulation in this context.
Hypovolemia can lead to hypothermia, but addressing the fluid deficit directly will also help stabilize temperature.
Focusing solely on temperature could delay crucial interventions to address the fluid loss and potentially worsen the patient's condition.
Rationale for Choice B:
An intact surgical incision is essential for proper wound healing and prevention of infection. However, in the context of active bleeding, it's not the priority outcome.
Maintaining adequate fluid volume is crucial to ensure perfusion of tissues, delivery of oxygen and nutrients, and proper organ function—all of which take precedence over incision integrity in this acute situation.
Addressing the fluid deficit will indirectly support wound healing by promoting tissue perfusion and reducing the risk of complications.
Rationale for Choice C:
Patient education is important, but it's not the most immediate priority in a patient with active bleeding and fluid volume deficit.
The patient's ability to comprehend and implement measures to reduce fluid loss may be compromised due to the hypovolemic state and potential cognitive effects.
Focusing on patient education at this stage could delay essential interventions to address the fluid loss and potentially worsen the patient's condition.
Rationale for Choice D:
Urine output is a sensitive and reliable indicator of renal perfusion and overall fluid status. In a patient with fluid volume deficit, maintaining a urine output of at least 30 mL/hour is a key indicator that the kidneys are receiving adequate blood flow and that fluid volume is being restored.
This outcome directly addresses the fluid deficit and serves as a measurable goal for fluid replacement therapy.
It takes priority over other choices because it directly reflects the patient's fluid status and the effectiveness of interventions to address the bleeding and fluid loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Employee Assistance Programs (EAPs): These programs focus on providing confidential counseling and support services to employees for personal and work-related issues, such as mental health, substance abuse, stress management, and family concerns. They do not play a role in determining nursing training requirements for intravenous line initiation.
Choice C rationale:
The MedWatch program: This is a voluntary reporting system for healthcare professionals and consumers to report adverse events and medication errors to the FDA. It's crucial for monitoring drug safety but does not establish training standards for nurses.
Choice D rationale:
The US Food and Drug Administration (FDA): This federal agency regulates food, drugs, medical devices, and cosmetics to ensure their safety and efficacy. While it sets standards for drug approval and labeling, it does not directly determine specific nursing training requirements.
Choice B rationale:
State Nurse Practice Acts: These laws, enacted by each state's legislature, define the scope of nursing practice, including the skills and tasks that nurses are legally authorized to perform. Intravenous line initiation is a skill that falls within the scope of nursing practice, and the specific training requirements for this skill are typically outlined in each state's Nurse Practice Act.
Key points:
State Nurse Practice Acts are the primary legal authority governing nursing practice within each state, including the necessary training for nurses to perform specific skills.
EAPs, MedWatch, and the FDA play important roles in healthcare but do not determine nursing training requirements
Nurses must be aware of the Nurse Practice Act in their state to ensure they are practicing within the legal scope of their profession and have received the required training for the skills they perform.
Correct Answer is C
Explanation
Choice A rationale:
Incorrect dosage form: Metformin is typically administered orally as a tablet or liquid suspension, not as a powder for reconstitution (PO).
Missing route of administration: The medication order does not specify the route of administration, such as oral (PO), intravenous (IV), or intramuscular (IM).
Potential for medication errors: The lack of clarity in the medication order could lead to errors in administration, such as giving the wrong dose or administering the medication by the wrong route.
Choice B rationale:
Incorrect dosage unit: Methotrexate is typically administered in milligrams (mg), not grams (g).
Potential for overdose: The order for 15.0 g of methotrexate is a very high dose that could lead to serious adverse effects, including toxicity and death.
Choice C rationale:
Correctly written: The medication order specifies the drug name (meropenem), the dose (1.0 g), the dosage form (IV), and the route of administration (IV).
Appropriate dosage range: The dose of 1.0 g of meropenem is within the typical dosage range for this antibiotic.
Clear and concise: The medication order is clear, concise, and easy to understand, which helps to reduce the risk of medication errors.
Choice D rationale:
Incorrect: While choices A and B are both incorrect, choice C is a correctly written medication order.
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