- The nurse is caring for a patient who has undergone major abdominal surgery.
4 hours post op
Urine output 45 ml
BP 120/80 mmHg
HR 90 beats/min
Weight 97.5 kg
24 hrs post op
urine output 20 ml/hr for past 2 hours
BP 100/50 mm Hg
HR 110 beats/m
Weight 99 kg
According to the 4 hours post-op assessment data and the 24 hour assessment data, the nurse understands that the weight change corresponds to an
fluid retention of 1.5 liters
fluid loss of 0.5 liters
equal intake and output due to insensible
The Correct Answer is A
A. Fluid retention of 1.5 liters: A weight gain of 1 kg corresponds to approximately 1 liter of fluid. The patient’s weight increased from 97.5 kg to 99 kg, indicating a gain of 1.5 kg, which reflects about 1.5 liters of fluid retained. This is supported by decreasing urine output, hypotension, and tachycardia, suggesting fluid imbalance.
B. Fluid loss of 0.5 liters: This is inconsistent with the patient’s weight gain and declining urine output, which point toward fluid retention rather than loss.
C. Equal intake and output due to insensible losses: Equal intake and output would result in relatively stable weight, not a 1.5 kg increase within 24 hours.
D. Fluid loss of 1.5 liters: A fluid loss of this amount would cause weight reduction, not weight gain, and would not align with the observed increase in body weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gastric residual volumes of 500 mL should be of concern: Residual volumes ≥500 mL are associated with increased risk of aspiration and feeding intolerance. At this threshold, the nurse should reassess feeding tolerance and notify the provider.
B. Gastric residual volume is checked every 2 hours: Routine checking every 2 hours is not recommended and may unnecessarily interrupt nutrition. Many guidelines discourage frequent checks unless the patient shows signs of intolerance.
C. Gastric residual volumes of 100 mL should be of concern: A residual of 100 mL is generally considered acceptable and not an indication to stop or hold enteral feedings. Using this low threshold can lead to underfeeding.
D. Gastric residual volume is checked every 6 hours: Scheduled routine checks at fixed intervals are no longer universally recommended. Assessment should be guided by patient condition and clinical signs rather than strict timing.
Correct Answer is ["A","D","F"]
Explanation
A. Uremia and fatigue: Accumulation of nitrogenous waste products in the blood (uremia) leads to symptoms such as fatigue, nausea, and malaise. These are hallmark clinical features of acute kidney injury (AKI) and reflect impaired renal excretory function.
B. Post renal: Post-renal causes refer to obstruction of urine flow, which is an etiology of AKI rather than a cardinal feature. While important for classification, it does not describe the presenting clinical signs.
C. Increase in urine output: Many cases of AKI present with oliguria or anuria rather than increased urine output. Polyuria may occur in the recovery phase but is not a primary diagnostic feature.
D. Azotemia and oliguria: Elevated blood urea nitrogen (BUN) and creatinine (azotemia) along with reduced urine output (oliguria) are classic features of AKI. They indicate impaired filtration and excretion of waste products.
E. Intrarenal: Intrarenal refers to damage within the kidney itself and is a cause of AKI rather than a cardinal feature. Structural or functional renal injury underlies intrarenal AKI.
F. Decreased glomerular filtration: Reduced glomerular filtration rate (GFR) is a central pathophysiological hallmark of AKI. It directly contributes to azotemia, fluid retention, and electrolyte imbalances seen in affected patients.
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