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 B
Explanation
Choice A reason: Sodium (Na+) imbalance can cause neurological symptoms such as confusion, seizures, or coma, but not abdominal pain or urinary retention.
Choice B reason: Calcium (Ca2+) imbalance can cause abdominal pain, urinary retention, and confusion, as well as muscle weakness, bone pain, and cardiac arrhythmias. These signs are the result of an inadequate supply of calcium, which is essential for nerve and muscle function, as well as bone health.
Choice C reason: Chloride (Cl-) imbalance can cause acid-base disorders such as metabolic acidosis or alkalosis, but not abdominal pain, urinary retention, or confusion.
Choice D reason: Phosphates (PO4^3^-) imbalance can cause bone and muscle problems, such as rickets, osteomalacia, or tetany, but not abdominal pain, urinary retention, or confusion.
Choice E reason: Potassium (K+) imbalance can cause cardiac and neuromuscular symptoms, such as arrhythmias, palpitations, muscle weakness, or paralysis, but not abdominal pain, urinary retention, or confusion.
Correct Answer is A
Explanation
Choice A reason: For an average adult, the total intake should be approximately equal to the total output every day¹². Therefore, if the patient's total output is 2200 mL, the total intake should also be around 2200 mL.
Choice B reason: 3000 mL is more than the recommended daily fluid intake for an average adult, which is about 2500 mL³. If the patient's intake is higher than their output, they may develop fluid overload or edema.
Choice C reason: 3800 mL is much more than the recommended daily fluid intake for an average adult, which is about 2500 mL³. If the patient's intake is higher than their output, they may develop fluid overload or edema.
Choice D reason: 2400 mL is slightly less than the recommended daily fluid intake for an average adult, which is about 2500 mL³. However, if the patient's intake is lower than their output, they may develop dehydration or electrolyte imbalance.
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