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 B
Explanation
Choice A reason: This is incorrect because polyuria is a sign of hyponatremia, not hypernatremia. Polyuria is the excessive production of urine, which can cause fluid loss and sodium dilution.
Choice B reason: This is correct because dry mucous membranes are a sign of hypernatremia. Dry mucous membranes are caused by dehydration, which can occur in hypernatremia due to fluid shifting from the intracellular to the extracellular space.
Choice C reason: This is incorrect because diarrhea is a sign of hyponatremia, not hypernatremia. Diarrhea is the frequent and watery passage of stool, which can cause fluid and electrolyte loss.
Choice D reason: This is incorrect because intense thirst is a sign of both hyponatremia and hypernatremia. Intense thirst is a result of the body's attempt to restore fluid balance and osmolarity.
Choice E reason: This is incorrect because vomiting is a sign of both hyponatremia and hypernatremia. Vomiting is a reflex action that expels the contents of the stomach, which can cause fluid and electrolyte loss or imbalance.
Correct Answer is A
Explanation
Choice A reason: For an average adult, the total intake should be approximately equal to the total output every day¹². Therefore, if the patient's total output is 2200 mL, the total intake should also be around 2200 mL.
Choice B reason: 3000 mL is more than the recommended daily fluid intake for an average adult, which is about 2500 mL³. If the patient's intake is higher than their output, they may develop fluid overload or edema.
Choice C reason: 3800 mL is much more than the recommended daily fluid intake for an average adult, which is about 2500 mL³. If the patient's intake is higher than their output, they may develop fluid overload or edema.
Choice D reason: 2400 mL is slightly less than the recommended daily fluid intake for an average adult, which is about 2500 mL³. However, if the patient's intake is lower than their output, they may develop dehydration or electrolyte imbalance.
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