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 C
Explanation
Choice A rationale:
Burning dried herbs is a form of traditional medicine, not allopathic medicine.
Traditional medicine encompasses a wide range of practices and therapies that have been used for centuries across different cultures.
It often relies on natural substances and processes, such as herbs, acupuncture, and massage, to promote healing and well- being.
While traditional medicine can offer valuable benefits, it's important to note that it's not always based on scientific evidence and its efficacy can vary depending on the specific practice and condition being treated.
Choice B rationale:
Tai chi exercises are a form of complementary and alternative medicine (CAM), not allopathic medicine.
CAM encompasses a diverse group of therapies that are not considered part of mainstream conventional medicine. Tai chi is a mind-body practice that involves gentle, flowing movements and deep breathing.
It has been shown to offer a range of health benefits, including reducing stress, improving balance, and easing pain.
However, it's important to note that tai chi is not a cure-all and should not be used as a substitute for conventional medical care when necessary.
Choice C rationale:
Prescription of antibiotic medication is a hallmark of allopathic medicine.
Allopathic medicine, also known as conventional or Western medicine, is based on the scientific understanding of the body and disease.
It focuses on diagnosing and treating specific diseases or conditions using medications, surgery, or other interventions that have been proven effective through rigorous scientific research.
Antibiotics are a type of medication that specifically targets and kills bacteria.
They are essential for treating bacterial infections, which can cause a wide range of illnesses, from minor skin infections to life- threatening pneumonia.
Choice D rationale:
Manipulation of the spine, also known as chiropractic care, is a form of CAM, not allopathic medicine. Chiropractic care focuses on the musculoskeletal system, particularly the spine.
Chiropractors use manual adjustments to the spine to relieve pain, improve range of motion, and restore function.
While some studies have shown that chiropractic care can be effective for certain conditions, such as lower back pain, it's important to note that it's not a cure-all and should not be used as a substitute for conventional medical care when necessary.
Correct Answer is C
Explanation
Choice A rationale:
Irrigating with sterile saline before swabbing can dilute the wound specimen and reduce the accuracy of the culture results. This is because the saline can wash away some of the bacteria that are present in the wound, making it more difficult to identify the specific bacteria that are causing the infection.
Additionally, swabbing the center of the wound may not collect a representative sample of the bacteria present, as bacteria can often be found in higher concentrations at the edges of the wound. This is because the edges of the wound are often where the tissue is most damaged and where the bacteria are able to enter the body more easily.
Choice B rationale:
Obtaining a sample of the drainage from the dressing on the wound may not be as accurate as collecting a sample directly from the wound. This is because the drainage may contain bacteria from the surrounding skin or environment, which could contaminate the culture results.
Additionally, the drainage may not contain a representative sample of the bacteria present in the wound, as some bacteria may not be able to drain out of the wound.
Choice D rationale:
Collecting a tissue sample from the wound during a surgical procedure is the most accurate way to obtain a culture. However, this is not always feasible or necessary.
It is often possible to obtain an accurate culture by collecting a sample from the wound using a sterile swab. This is a less invasive procedure and can be done at the bedside.
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