What is the priority outcome for a patient with the nursing diagnosis of fluid volume deficit related to ongoing postoperative bleeding?

The patient’s temperature will remain within normal limits.

The patient’s surgical incision will remain intact with sutures.

The patient will verbalize measures to reduce fluid volume loss.

The patient’s urine output will be at least 30 mL/hour.

Answer and Explanation

The Correct Answer is D

Rationale for Choice A:

While maintaining normal body temperature is important for overall health, it's not the most immediate priority in a patient with fluid volume deficit due to ongoing bleeding. Fluid volume status takes precedence over temperature regulation in this context.

Hypovolemia can lead to hypothermia, but addressing the fluid deficit directly will also help stabilize temperature.

Focusing solely on temperature could delay crucial interventions to address the fluid loss and potentially worsen the patient's condition.

Rationale for Choice B:

An intact surgical incision is essential for proper wound healing and prevention of infection. However, in the context of active bleeding, it's not the priority outcome.

Maintaining adequate fluid volume is crucial to ensure perfusion of tissues, delivery of oxygen and nutrients, and proper organ function—all of which take precedence over incision integrity in this acute situation.

Addressing the fluid deficit will indirectly support wound healing by promoting tissue perfusion and reducing the risk of complications.

Rationale for Choice C:

Patient education is important, but it's not the most immediate priority in a patient with active bleeding and fluid volume deficit.

The patient's ability to comprehend and implement measures to reduce fluid loss may be compromised due to the hypovolemic state and potential cognitive effects.

Focusing on patient education at this stage could delay essential interventions to address the fluid loss and potentially worsen the patient's condition.

Rationale for Choice D:

Urine output is a sensitive and reliable indicator of renal perfusion and overall fluid status. In a patient with fluid volume deficit, maintaining a urine output of at least 30 mL/hour is a key indicator that the kidneys are receiving adequate blood flow and that fluid volume is being restored.

This outcome directly addresses the fluid deficit and serves as a measurable goal for fluid replacement therapy.

It takes priority over other choices because it directly reflects the patient's fluid status and the effectiveness of interventions to address the bleeding and fluid loss.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

While providing meticulous oral care and allowing ice chips for dry mouth can promote comfort, it does not address the primary concern of absent bowel sounds.

Ice chips could potentially stimulate bowel activity, but this is not a reliable or recommended method for managing absent bowel sounds in the immediate postoperative period.

It's essential to prioritize actions that assess and address the potential causes of absent bowel sounds, as they can indicate serious complications.

Choice B rationale:

Notifying the surgeon immediately and preparing for emergency surgery is not the appropriate first course of action in this situation.

Emergency surgery would be considered only if there were clear signs of a life-threatening complication, such as bowel perforation or peritonitis.

These complications would typically present with additional symptoms such as severe abdominal pain, fever, and hemodynamic instability.

Absent bowel sounds alone, without other concerning signs, do not warrant immediate surgical intervention.

Choice D rationale:

Allowing the patient to have clear liquids as tolerated is not appropriate when bowel sounds are absent. Introducing oral intake before bowel function has returned can increase the risk of nausea, vomiting, and aspiration.

It's crucial to wait for the return of bowel sounds before initiating oral intake to ensure proper digestion and minimize complications.

Choice C rationale:

Keeping the patient NPO (nothing by mouth) is the most appropriate action when bowel sounds are absent after major abdominal surgery.

This allows the bowel to rest and recover from the surgical manipulation.

It also prevents potential complications such as aspiration and nausea/vomiting that could arise from premature oral intake.

Documenting the absence of bowel sounds in the patient's medical record is essential for communication among healthcare providers and for monitoring the patient's progress.

This documentation provides a clear record of the patient's clinical status and facilitates appropriate decision-making regarding further interventions.

A. The patient is experiencing a moderate allergic reaction and should improve shortly. B. These symptoms are probably due to food poisoning because very few patients have true allergic responses. C. The patient is having an anaphylactic reaction and emergency interventions should be started. D. The patient is having a mild reaction that can be treated easily with an antihistamine.

Correct Answer is C

Explanation

Rationale for Choice A:

Incorrect. While the patient is experiencing an allergic reaction, it is not moderate. The presence of difficulty breathing and a drop in blood pressure are signs of a severe, life-threatening anaphylactic reaction.

Anaphylaxis is a severe, rapid-onset allergic reaction that can lead to death if not treated promptly. It typically involves multiple body systems, including the skin, respiratory system, cardiovascular system, and gastrointestinal system.

Moderate allergic reactions typically present with localized symptoms such as hives, itching, and redness. They do not typically involve respiratory or cardiovascular compromise.

Rationale for Choice B:

Incorrect. The patient's symptoms are not consistent with food poisoning. Food poisoning typically causes gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal cramps. It does not typically cause hives, difficulty breathing, or a drop in blood pressure.

The timing of the symptoms, occurring 2 hours after receiving an antibiotic, strongly suggests an allergic reaction to the medication.

Rationale for Choice C:

Correct. The patient's symptoms are consistent with anaphylaxis, a severe allergic reaction that requires immediate emergency treatment.

Key features of anaphylaxis include:

Skin involvement (hives, itching, flushing, swelling)

Respiratory distress (difficulty breathing, wheezing, tightness in the chest) Cardiovascular compromise (drop in blood pressure, lightheadedness, fainting) Gastrointestinal symptoms (nausea, vomiting, diarrhea)

Swelling of the tongue or throat

Rationale for Choice D:

Incorrect. The patient's reaction is not mild and cannot be treated with an antihistamine alone. Antihistamines are effective for mild allergic reactions, but they are not sufficient to treat anaphylaxis.

Anaphylaxis requires immediate treatment with epinephrine, which is a life-saving medication that can reverse the effects of the allergic reaction.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

What is the priority outcome for a patient with the nursing diagnosis of fluid volume deficit related to ongoing postoperative bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Four hours after major abdominal surgery, the nurse notes that the patient does not have any bowel sounds. What is the appropriate action for the nurse to take?

Correct Answer is C

Explanation

The nurse notes that the patient is scratching and has hives 2 hours after receiving a dose of antibiotic medication.The patient soon starts having difficulty breathing and his blood pressure drops. What is the correct analysis of the patient’s condition?

Correct Answer is C

Explanation

The nurse is to administer 3 mL of medication intramuscularly to an adult patient. Which is the appropriate site for the injection?

A patient is admitted to the cardiac unit.Everyone admitted to the cardiac unit will have an EKG done unless otherwise ordered. This is an example of which type of order?

Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism?

Which factor contributes to the formation of a pressure injury when a patient’s body slides downward to the foot of the bed?

The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.Which are the appropriate actions of the nurse? (Select all that apply.)

How will the nurse administer a nitroglycerin sublingual tablet to the patient?

If a nurse needs to administer 3 mL of medication intramuscularly to an adult patient, which site should be used for the injection?

Which medication order is written appropriately?