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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool used for verbal or written reports, focusing on concise information transfer during transitions of care or urgent situations, not a comprehensive charting system based on exceptions.

Choice B rationale

Focused charting centers on specific patient problems or concerns, using a DAR (Data, Action, Response) format. It addresses particular issues in detail rather than documenting only deviations from the norm.

Choice C rationale

Charting by exception (CBE) is a documentation system where nurses only document findings that are outside the normal range or significant changes in a patient's condition. Standardized care and expected outcomes are assumed to be met and are not routinely documented, saving time and reducing redundancy.

Choice D rationale

SOAP (Subjective, Objective, Assessment, Plan) is a problem-oriented charting method commonly used by physicians and other healthcare providers to organize patient information around specific problems identified during assessment.

A. "Documentation enables providers to monitor the nurse.”. B. "Documentation provides a communication tool for the health care team.”. C. "Documentation provides information for a client audit.”. D. "Documentation facilitates reimbursement from the local government.”.

Correct Answer is B

Explanation

Choice A rationale

While documentation can be reviewed by providers, its primary purpose is not to monitor nurses' performance. Monitoring occurs through various quality assurance processes, and documentation serves a broader range of functions beyond individual nurse oversight.

Choice B rationale

Documentation acts as a central communication hub for all members of the healthcare team, including physicians, nurses, therapists, and other specialists. It ensures continuity of care by providing a shared understanding of the client's condition, treatments, and responses, facilitating informed decision-making and collaboration.

Choice C rationale

Although documentation can be used for audits, such as financial or quality audits, this is not its primary purpose. The main goal of documentation is to provide a comprehensive record of patient care for effective communication and continuity.

Choice D rationale

While accurate documentation supports billing and reimbursement processes from various payers, including government entities, this is a secondary outcome. The primary aim of documentation is to ensure high-quality patient care through clear and comprehensive information sharing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse charts only additional treatments done, abnormal findings, changes in patient condition, and new concerns, the system of documentation is:

Correct Answer is C

Explanation

A nurse is preparing to document a client's information in the electronic medical record.Which of the following nursing statements identifies the purpose of documentation?

Correct Answer is B

Explanation

Fluid volume deficit related to:

A nurse is discussing informatics with a newly licensed nurse.The nurse identifies that informatics is defined as the use of information and technology for which of the following?

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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?

A nurse is discussing the advantages and challenges of electronic health records (EHRS) with a newly licensed nurse.Which of the following should the nurse include as an advantage?

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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?