Which fluid output measurement is the most concerning for a nurse?
60 mL of urine in a 2-hour period
720 mL of urine in a 24-hour period
600 mL of urine in a 10-hour period
100 mL of urine in a 5-hour period
The Correct Answer is D
Choice A reason: 60 mL of urine in a 2-hour period is not very concerning for a nurse, as it is within the normal range of urine output. The average urine output for an adult is about 1 to 2 L per day, or 40 to 80 mL per hour¹.
Choice B reason: 720 mL of urine in a 24-hour period is slightly below the normal range, but not alarming. It may indicate mild dehydration or reduced fluid intake, but it is not a sign of fluid volume excess or kidney failure¹.
Choice C reason: 600 mL of urine in a 10-hour period is also within the normal range of urine output, and does not indicate any problem with fluid balance or renal function¹.
Choice D reason: 100 mL of urine in a 5-hour period is the most concerning for a nurse, as it indicates oliguria, or abnormally low urine output. Oliguria is defined as urine output less than 400 mL per day, or less than 20 mL per hour². It may be caused by acute or chronic kidney injury, urinary obstruction, shock, dehydration, or fluid volume excess². Oliguria can lead to fluid overload, electrolyte imbalance, acidosis, and uremia, and requires immediate medical attention².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because normal saline is not indicated for this client. Normal saline is a isotonic solution that does not alter the acid-base balance. The client has respiratory alkalosis, which is caused by hyperventilation and results in a high pH and a low PaCO2.
Choice B reason: This is incorrect because Allen's test is not relevant for this client. Allen's test is a test to assess the patency of the radial and ulnar arteries before performing an arterial blood gas (ABG) sampling or cannulation. The client already has ABG results, so there is no need to perform Allen's test.
Choice C reason: This is incorrect because increasing breathing would worsen the client's condition. Increasing breathing would cause the client to exhale more carbon dioxide, which would lower the PaCO2 and raise the pH even more. This would increase the severity of respiratory alkalosis.
Choice D reason: This is correct because slowing down breathing would help the client to correct the respiratory alkalosis. Slowing down breathing would allow the client to retain more carbon dioxide, which would increase the PaCO2 and lower the pH. This would bring the acid-base balance closer to normal.
Correct Answer is A
Explanation
Choice A reason: Renal failure can cause hyperkalemia because the kidneys are unable to excrete excess potassium from the body. This can lead to high levels of potassium in the blood, which can affect the heart and muscles.
Choice B reason: Diarrhea can cause hypokalemia, not hyperkalemia, because it can lead to loss of potassium from the gastrointestinal tract. This can result in low levels of potassium in the blood, which can also affect the heart and muscles.
Choice C reason: Blood transfusion can cause hyperkalemia if the blood is old or hemolyzed, meaning that the red blood cells have broken down and released potassium into the plasma. This can increase the potassium levels in the recipient's blood.
Choice D reason: Diaphoresis, or sweating, can cause hypokalemia, not hyperkalemia, because it can lead to loss of potassium from the skin. This can also lower the potassium levels in the blood.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.