You note the following findings on your patient: (see chart below)
|
Vital Signs |
Blood Pressure: 138/84 Heart Rate: 98 beats per minute Respiratory Rate: 18 breaths per minute Temperature: 99.6F Pulse oximetry: 97% on room air Pain: 7/10 |
|
Intake and output |
Intake for past 12 hours: 2150mL Output for past 12 hours: 150mL Meals: 100% breakfast 75% lunch 90% dinner |
Based on these findings, what intervention should you implement first?
Check the patient's urinalysis.
Notify the provider of the patient's pain 7/10
Perform a bladder scan
Assess the daily weight.
The Correct Answer is C
A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.
B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.
C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.
D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Determine the dose per administration:
- 1000 mg ÷ 250 mg/capsule = 4 capsules per dose
Calculate the total per day:
- Since the order is every 12 hours, the medication is given twice a day
- 4 capsules per dose × 2 doses per day = 8 capsules per day
Correct Answer is C
Explanation
A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.
B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.
C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.
D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.
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