Which fluid output measurement is the most concerning for a nurse?
60 mL of urine in a 2-hour period
720 mL of urine in a 24-hour period
600 mL of urine in a 10-hour period
100 mL of urine in a 5-hour period
The Correct Answer is D
Choice A reason: 60 mL of urine in a 2-hour period is not very concerning for a nurse, as it is within the normal range of urine output. The average urine output for an adult is about 1 to 2 L per day, or 40 to 80 mL per hour¹.
Choice B reason: 720 mL of urine in a 24-hour period is slightly below the normal range, but not alarming. It may indicate mild dehydration or reduced fluid intake, but it is not a sign of fluid volume excess or kidney failure¹.
Choice C reason: 600 mL of urine in a 10-hour period is also within the normal range of urine output, and does not indicate any problem with fluid balance or renal function¹.
Choice D reason: 100 mL of urine in a 5-hour period is the most concerning for a nurse, as it indicates oliguria, or abnormally low urine output. Oliguria is defined as urine output less than 400 mL per day, or less than 20 mL per hour². It may be caused by acute or chronic kidney injury, urinary obstruction, shock, dehydration, or fluid volume excess². Oliguria can lead to fluid overload, electrolyte imbalance, acidosis, and uremia, and requires immediate medical attention².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Renal failure can cause hyperkalemia because the kidneys are unable to excrete excess potassium from the body. This can lead to high levels of potassium in the blood, which can affect the heart and muscles.
Choice B reason: Diarrhea can cause hypokalemia, not hyperkalemia, because it can lead to loss of potassium from the gastrointestinal tract. This can result in low levels of potassium in the blood, which can also affect the heart and muscles.
Choice C reason: Blood transfusion can cause hyperkalemia if the blood is old or hemolyzed, meaning that the red blood cells have broken down and released potassium into the plasma. This can increase the potassium levels in the recipient's blood.
Choice D reason: Diaphoresis, or sweating, can cause hypokalemia, not hyperkalemia, because it can lead to loss of potassium from the skin. This can also lower the potassium levels in the blood.
Correct Answer is A
Explanation
Choice A reason: This is correct because respiratory acidosis is a condition where the blood pH is lower than the normal range of 7.35 to 7.45, due to impaired gas exchange or hypoventilation, which causes carbon dioxide to accumulate in the blood. COPD is a chronic lung disease that obstructs the airways and reduces the oxygen intake and carbon dioxide output. This leads to respiratory acidosis in the patient.
Choice B reason: This is incorrect because respiratory alkalosis is a condition where the blood pH is higher than the normal range of 7.35 to 7.45, due to hyperventilation, which lowers the carbon dioxide in the blood. COPD does not cause hyperventilation, but rather hypoventilation.
Choice C reason: This is incorrect because metabolic alkalosis is a condition where the blood pH is higher than the normal range of 7.35 to 7.45, due to a loss of acids or an excess of bases in the body. COPD does not affect the metabolic system directly, but rather the respiratory system.
Choice D reason: This is incorrect because metabolic acidosis is a condition where the blood pH is lower than the normal range of 7.35 to 7.45, due to an excess of acids or a loss of bases in the body. COPD does not affect the metabolic system directly, but rather the respiratory system.
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