The patient has a goal of maintaining urinary output of at least 80 mL/hour as part of the nursing care plan.
However, the patient's urinary output for the shift was only 20 mL/hour.
What is the appropriate action of the nurse?
Inform the patient that the urinary output goal for the shift was not met.
Contact the physician to obtain an order for a diuretic.
Change the goal to: patient will maintain urinary output of at least 20 mL/hour.
Reassess the patient to determine why the urinary output was less than 80 mL/hour.
The Correct Answer is D
Choice A rationale
Informing the patient that the urinary output goal was not met, without further investigation, does not address the underlying cause of the low output and fails to implement necessary interventions. It is a superficial action that lacks a scientific basis for improving the patient's condition.
Choice B rationale
Contacting the physician for a diuretic order without first assessing the cause of the reduced urinary output could be premature and potentially harmful. Diuretics increase urine production but may not be appropriate if the low output is due to dehydration, decreased renal perfusion, or other factors. Normal urine output is typically 0.5 to 1 mL/kg/hour.
Choice C rationale
Changing the goal to match the current inadequate output is inappropriate as it lowers the standard of care and fails to address a potentially serious underlying physiological issue. The initial goal of 80 mL/hour likely reflects the patient's needs based on their condition and weight.
Choice D rationale
Reassessing the patient is the most appropriate initial action. This allows the nurse to gather crucial data such as vital signs, hydration status, medication history, and any factors that might be contributing to the decreased urinary output. Understanding the cause is essential for implementing targeted and effective interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Performing a physical examination involves the systematic assessment of a patient's body to identify signs of health or illness. Listening to lung sounds, palpating peripheral pulses, and obtaining vital signs are all fundamental components of a physical examination aimed at gathering objective data about the patient's current condition.
Choice B rationale
Establishing priorities for outcomes involves setting goals for patient care based on identified nursing diagnoses and collaborative problems. While the nurse's assessment data will inform the development of outcomes, the initial actions described focus on data collection, not outcome identification.
Choice C rationale
Demonstrating diagnostic reasoning is the cognitive process of analyzing assessment data to arrive at a nursing diagnosis or identify a collaborative problem. While the nurse is gathering data that will contribute to diagnostic reasoning, the actions described are the data collection phase itself, not the analysis.
Choice D rationale
Setting time frames for interventions involves establishing specific schedules for nursing actions aimed at achieving patient outcomes. The nurse's immediate actions upon the patient's arrival are focused on rapid assessment to understand the patient's immediate needs, not on scheduling future interventions.
Correct Answer is B
Explanation
Choice A rationale
Maintaining a normal respiratory rate (typically 12-20 breaths per minute for adults) and pulse rate (typically 60-100 beats per minute for adults) are general indicators of stable physiological function but do not directly confirm airway clearance. While improved airway clearance can contribute to these stable vital signs, other factors can also influence them.
Choice B rationale
A clear airway directly addresses the nursing diagnosis of ineffective airway clearance. If the patient's airway remains unobstructed, thick sputum can be expectorated or managed, and narrowed airways will not impede airflow. This outcome specifically targets the problem identified in the nursing diagnosis.
Choice C rationale
Resting comfortably by the morning is a desirable outcome reflecting overall well-being, but it is not a direct measure of airway clearance. While improved breathing can contribute to comfort, other factors like pain or anxiety can also affect rest.
Choice D rationale
Absence of shortness of breath (dyspnea) and anxiety suggests improved respiratory function, but it doesn't definitively confirm the airway is clear of thick sputum or that narrowed airways are no longer a problem. The patient could still have airway issues without experiencing these symptoms consistently.
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