You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with the following report
Dr. Smith, I'm calling about Mrs. P., your 65-year-old patient in CCU 10 . Her urine output for the past 2 hours totaled only 40 mL. She arrived from surgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and her blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusion of normal saline at 100 mL per hour. Her right atrial pressure through the subclavian central line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider increasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient's history and vital signs is:
a. Situation
b. Background
c. Assessment
d. Recommendation
B
The history and vital signs are part of the background. Information regarding the low urine output is the situation. Information regarding possible hypovolemia is part of the nurse's assessment, and the suggestion for fluids is the recommendation.
You might also like to view...
What percent of first-trimester pregnancies spontaneously abort?
a. 5% to 10% b. 10% to15% c. 20% to 25% d. 40% to 50%
If the nurse asks a patient with schizophrenia if any visitors came on Sunday, the response that indicates loose association is:
a. "No." b. "Yes! I had 90 visitors who came from every state in the union." c. "Sunday is the Sabbath. Do we have visitors on the Sabbath?" d. "We visited Yellowstone Park last summer."
With which client is it most important for the nurse to take special precautions because of an increased susceptibility to infection as a result of medical therapy?
A. The 38-year-old woman taking contraceptives B. The 38-year-old man with diabetes mellitus taking insulin C. The 58-year-old man 5 years after a myocardial infarction taking aspirin daily D. The 58-year-old woman with rheumatoid arthritis taking corticosteroids daily
A healthy, active 72-year-old woman asks a nurse if it is safe to take dietary supplements and, if so, what should be taken? What would the nurse tell her?
A) Yes, take calcium, vitamin D, and vitamin B12. B) Yes, take iron, folic acid, and iodine. C) No, instead increase intake of carbohydrates. D) No, increase fat intake for fat-soluble vitamins.