The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?
Urine output of 30 mL/hr
Blood pressure is 90/40
IV site is infiltrated
Oral fluid intake of 100 mL for 8 hours
The Correct Answer is B
Choice A reason: Urine output of 30 mL/hr is concerning as it is on the lower end of normal and can indicate dehydration or impaired renal function. However, in this context, it is less immediately alarming compared to severely low blood pressure.
Choice B reason: Blood pressure of 90/40 is critically low and indicates hypotension, which can be a sign of severe dehydration or shock, especially in a patient with ongoing nausea and vomiting. This requires immediate attention and intervention to stabilize the patient and prevent further complications.
Choice C reason: An infiltrated IV site is a problem that needs to be addressed to ensure proper administration of fluids and medications. However, it is not as immediately life-threatening as hypotension.
Choice D reason: Oral fluid intake of 100 mL for 8 hours is inadequate, suggesting that the patient may be dehydrated. While concerning, it is not as acutely critical as low blood pressure, which directly affects perfusion and organ function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The nurse assistant typically performs tasks such as patient hygiene, ambulation, and basic monitoring under the supervision of registered nurses. They are not usually responsible for documenting vital signs during the intra-operative period.
Choice B reason: The anesthesiologist is primarily focused on managing the patient's anesthesia and monitoring their physiological status during surgery. While they do keep track of vital signs, the formal documentation is typically the responsibility of the circulating nurse.
Choice C reason: The scrub nurse is focused on maintaining the sterile field, handling surgical instruments, and assisting the surgeon. They do not leave the sterile field to document vital signs.
Choice D reason: The circulating nurse is responsible for overall patient care in the operating room, including documentation of vital signs. They manage the operating room environment, ensure patient safety, and record all necessary information during the intra-operative period.
Correct Answer is C
Explanation
Choice A reason: Eating foods high in potassium can be important for patients taking diuretics, as diuretics can cause potassium loss. However, for SIADH patients, this is not a primary focus unless they are on diuretics that specifically lead to potassium loss.
Choice B reason: Limiting fluid intake is crucial for patients with SIADH to prevent fluid overload and hyponatremia. This statement aligns with proper management of the condition.
Choice C reason: Patients with SIADH need to carefully manage their sodium intake. Rather than reducing sodium, they often need to maintain or increase their sodium intake to help counteract the effects of SIADH, which causes dilutional hyponatremia (low blood sodium levels). Therefore, this statement indicates a need for additional instruction.
Choice D reason: Weighing oneself daily is an important practice for SIADH patients to monitor for sudden weight changes, which can indicate fluid imbalances. This statement is appropriate and does not require additional instruction.
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