At the end of shift, you are calculating intake and output on your pat lent who was admited for a non- emergent gall bladder removal. She is alert and oriented and able to recall the amount of fluid she has drank all day. You can calculate the amount of IV fluids administered. Her intake is 2500ml and her output is 1200ml from a catheter bag. You realize she is not excreting enough urine me for water she is taking in. What is the most appropriate next step to determine if she is retaining water?
Put a hat in the toilet to collect proper output.
Assess your patient’s lower extremities and lungs for fluid retention.
Educate her on the importance of writing down all fluids she is drinking.
Document the numbers anyway, there is a probable error with the intake number.
The Correct Answer is B
. Assess your patient’s lower extremities and lungs for fluid retention.
If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for fluid retention. This can help determine if the patient is retaining water and if further intervention is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
. Assess your patient’s lower extremities and lungs for fluid retention.
If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for fluid retention. This can help determine if the patient is retaining water and if further intervention is necessary.
Correct Answer is C
Explanation
An Incentive Spirometer is a device that helps patients take deep breaths and improve their lung function. It encourages patients to take deep breaths and to hold them for a few seconds. The device also helps to monitor and measure lung volume. By using an incentive spirometer, MA can expand her lung volume as much as possible and allow for proper oxygen blood exchange within the alveoli. This is an important technique to help prevent pneumonia and other respiratory complications.
The other options mentioned, 4L of oxygen via Nasal Cannula, Fluter Valve, and Abdominal Binder, are not appropriate devices to help MA achieve proper breathing techniques and expand lung volume. 4L of oxygen via Nasal Cannula is used to provide supplemental oxygen to patients who have difficulty breathing. Fluter Valve is a handheld device used for airway clearance in patients with chronic obstructive pulmonary disease (COPD) or cystic fibrosis. An abdominal binder is a wrap that is placed around the abdomen to support the abdominal muscles and help reduce pain after surgery or injury. These devices do not help improve lung function and are not appropriate for MA's condition.
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