Which of the information below obtained when caring for a patient who has been admited for evaluation of diabetes insipidus will be of greatest concern to the nurse?
The patient has a urine output of 800 ml/hr.
The patient is confused and lethargic.
The patient's urine specific gravity is 1.003.
The patient had a recent head injury.
The Correct Answer is B
Diabetes insipidus is a condition where the body is not able to regulate water balance properly, leading to excessive urine output and dehydration. The patient's urine output of 800 ml/hr (option A) and low urine specific gravity of 1.003 (option C) is consistent with diabetes insipidus and requires monitoring, but they are not as immediately concerning as the patient's confusion and lethargy.
Confusion and lethargy may indicate severe dehydration, electrolyte imbalances, or even brain swelling (if the patient had a recent head injury, as mentioned in option D). These symptoms require immediate attention to prevent further complications and ensure the patient's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Counting sponges, needles, and surgical instruments is an intraoperative activity that is specific to the circulating function of the perioperative nurse. The nurse is responsible for maintaining an accurate count of all surgical items to prevent leaving any foreign objects inside the patient after the surgery. This is a crucial task to ensure patient safety and prevent any potential complications that may arise from such errors.
Option a. admitting, identifying, and assessing the patient, is a preoperative function that is usually performed by the preoperative nurse.
Option c. passing instruments to the surgeon and assistants, is a scrub nurse function that requires knowledge of the surgical procedure and a sterile technique.
Option d. preparing the instrument table and sterile equipment is also a scrub nurse function that requires expertise in sterile technique, knowledge of surgical procedures, and the ability to maintain a sterile environment.
Correct Answer is B
Explanation
The pH value is less than the normal range of 7.35-7.45, indicating acidosis. The PaCO2 value is elevated above the normal range of 35-45 mmHg, indicating respiratory acidosis. The PaO2 value is lower than normal, but not significantly low enough to indicate hypoxemia. The HCO3- level is within the normal range, but not significantly high enough to indicate metabolic compensation for respiratory acidosis.
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