A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?
Urine is cloudy after sitting in the urinal for 6 hours.
First-voided urine in the morning has a strong odor.
Urine output of 175 mL in the past 8 hours.
Urine output of 2,200 mL in the past 24 hours.
The Correct Answer is C
A. Cloudy urine may indicate sediment or the presence of protein but does not necessarily require immediate notification to the provider.
B. A strong odor in the first-voided urine can be normal or due to dehydration or dietary factors, and does not immediately warrant concern.
C. A urine output of 175 mL in 8 hours is significantly low and indicates possible oliguria, which is a concern for impaired renal function and should be reported to the provider.
D. A urine output of 2,200 mL in 24 hours can indicate normal or excessive output (polyuria), but it is less concerning than oliguria and does not require immediate notification.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.
Correct Answer is D
Explanation
A. Assessing the pedal pulses with a Doppler device is not necessary in this situation; the focus should be on the apical pulse due to the irregularity noted in the radial pulse.
B. Assessing the pedal pulses for a full minute does not address the irregularity of the radial pulse and is not the priority.
C. While assessing the apical pulse is appropriate, using a Doppler device is not required unless there are difficulties in obtaining the pulse normally.
D. Assessing the apical pulse for a full minute is the correct action because it provides a more accurate reflection of the heart's rhythm and rate, especially when there is an irregular radial pulse.