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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 A

Explanation

A. Oliguria: Reduced urine output (oliguria) can indicate acute rejection due to decreased renal function. Other signs include fever, hypertension, graft tenderness, and swelling.

B. Temperature 36.1° C (97.0° F): Rejection often causes fever, not a low temperature.

C. Weight loss: Weight gain (fluid retention) is more common with rejection.

D. Insomnia: Insomnia is not a direct sign of rejection.

A. The development of malignant hyperthermia B. The development of fluid volume excess C. The development of an allergic response to the pain medication D. The development of an infection.

Correct Answer is A

Explanation

A. The development of malignant hyperthermia: Malignant hyperthermia (MH) is a life-threatening reaction to certain anesthetics (e.g., succinylcholine, halothane). It causes rapid muscle breakdown, severe hyperthermia, tachycardia, muscle rigidity, and metabolic acidosis. Immediate treatment with IV dantrolene and cooling measures is required.

B. The development of fluid volume excess: Fluid overload may cause hypertension and pulmonary edema but does not cause sudden high fever.

C. The development of an allergic response to the pain medication: Drug allergies typically present with rash, itching, or anaphylaxis, not extreme fever.

D. The development of an infection. Post-op infections usually develop over several days, not immediately in PACU.

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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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