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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Shearing force is the primary factor that contributes to the formation of pressure injuries when a patient's body slides downward. It occurs when two surfaces move in opposite directions, causing stress and strain on the tissues between them.

Compression of Tissues: When the patient's body slides downward, the skin and underlying tissues are compressed between the bony prominences (such as the sacrum or heels) and the surface of the bed. This compression restricts blood flow to the area, depriving the tissues of oxygen and nutrients.

Tissue Stretching and Tearing: As the body slides, the skin and underlying tissues are also stretched and pulled in opposite directions. This shearing force disrupts the normal alignment of cells and tissues, leading to microscopic tears and damage.

Impaired Blood Flow: Shearing force further compromises blood flow by stretching and compressing blood vessels. This reduces the delivery of oxygen and nutrients to the tissues, while also hindering the removal of waste products.

Tissue Damage and Necrosis: The combination of compression, stretching, and impaired blood flow leads to cell death and tissue necrosis. This is the hallmark of pressure injuries, which can range from superficial blisters to deep ulcers that extend into muscle and bone.

Factors that Increase Shearing Force: Certain factors can increase the risk of shearing force and pressure injury development, including:

Increased moisture (from sweat or incontinence) Decreased mobility

Poor skin integrity

Malnutrition

Friction from bedsheets

In conclusion, shearing force is the main factor that contributes to pressure injury formation when a patient's body slides downward. It disrupts blood flow, damages tissues, and can lead to significant wounds.

A. The patient’s last bowel movement was before surgery, 4 days ago. B. The patient has refused enoxaparin injections after surgery. C. The patient’s platelet count was 45,000/mm^3 this morning. D. The patient required transfusion of two units of packed red blood cells.

Correct Answer is B

Explanation

Choice A rationale:

A patient's last bowel movement being 4 days ago does not directly increase their risk of pulmonary embolism (PE). While constipation can be a risk factor for deep vein thrombosis (DVT), which can lead to PE, it is not a significant risk factor on its own.

It's important to assess for other risk factors for DVT, such as immobility, recent surgery, or a history of blood clots, in conjunction with constipation.

Choice C rationale:

A platelet count of 45,000/mm^3 is low (thrombocytopenia), but it does not directly increase the risk of PE.

In fact, a low platelet count can sometimes hinder clot formation. However, it's important to monitor patients with thrombocytopenia for bleeding risks, as they may be more prone to bleeding complications.

Choice D rationale:

While receiving a transfusion of two units of packed red blood cells can increase blood viscosity, which could theoretically slightly increase the risk of PE, it is not a major risk factor.

Patients who receive transfusions are often already at an elevated risk of PE due to other underlying conditions or surgeries. It's essential to assess for other risk factors in these patients.

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What is the priority outcome for a patient with the nursing diagnosis of fluid volume deficit related to ongoing postoperative bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which factor contributes to the formation of a pressure injury when a patient’s body slides downward to the foot of the bed?

Correct Answer is A

Explanation

Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism?

Correct Answer is B

Explanation

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