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A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record?

Nocturia

Enuresis

Anuria

Oliguria

Answer and Explanation

The Correct Answer is D

A. Nocturia: Excessive nighttime urination, not decreased urine output.

B. Enuresis: Involuntary urination, commonly bedwetting in children.

C. Anuria: Severe lack of urine output (< 100 mL/24 hrs), which is worse than oliguria.

D. Oliguria: Oliguria is defined as urine output < 400 mL/24 hours. 250 mL in 24 hours qualifies as oliguria.

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Correct Answer is C

Explanation

A. Request a neurological consult: This is likely a metabolic issue (hypocalcemia), not a neurological disorder.

B. Have another nurse take their blood pressure: Rechecking BP does not address the underlying cause of the abnormal movement.

C. Review the client's lab values: Carpopedal spasm (Trousseau's sign) during BP measurement suggests hypocalcemia. The nurse should check serum calcium levels to confirm.

D. Call the healthcare provider for orders: The nurse should first review lab results to provide accurate data when notifying the provider.

A. Obtain vital signs B. Bolus the client with 1000 m of normal saline C. Turn off the dialysis machine immediately D. Notify the health care provider as soon as possible

Correct Answer is A

Explanation

A. Obtain vital signs: Dizziness and lightheadedness during dialysis suggest hypotension, a common complication. The nurse should first assess vital signs to determine the severity before taking further action.

B. Bolus the client with 1000 mL of normal saline: If the client is hypotensive, a smaller fluid bolus (e.g., 250–500 mL) would be more appropriate.

C. Turn off the dialysis machine immediately: Stopping dialysis abruptly may cause fluid overload and other complications. The rate may need adjustment but not immediate cessation.

D. Notify the health care provider as soon as possible: While important, assessing the client’s current status is the priority before contacting the provider.

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A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record?

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