The patient is on postoperative day 1 after having undergone a TURP procedure. He has continuous bladder irrigation (CBI). Actual urine output during continuous bladder irrigation is calculated by:
a. measuring and recording all fluid output in the drainage bag.
b. measuring the total output and deducting the total of the irrigating and intravenous solutions.
c. adding the total of the intravenous and irrigating solutions and then deducting the amount of output.
d. measuring total output and deducting the amount of irrigating solution used.
ANS: D
To determine urine output, the nurse will subtract the amount of irrigation fluid used with the Foley catheter output to calculate urine output.
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The nurse is assisting with discharging a patient with myasthenia gravis after hospitalization for severe respiratory distress. Which statement by the patient indicates that the nurse's discharge teaching has been effective?
a. "I will take my anticholinergic medication to prevent developing respiratory distress again." b. "If I develop muscle cramping, I can take quinine as needed." c. "I know I should take my Prostigmin as needed, whenever I feel short of breath." d. "I have to take my Prostigmin exactly as prescribed without skipping a dose."
The nurse is beginning an assessment with a pregnant patient from a non-English-speaking culture. The interpreter is having difficulty understanding what the patient is trying to say and the patient is becoming frustrated
Which nursing diagnosis would be the most appropriate for this situation? A) Fear B) Anxiety C) Powerlessness D) Impaired verbal communication
When reviewing the literature related to legislation to restrict mandatory overtime for nurses, which point would be an expected finding?
A) Every state has defeated it since it has been introduced. B) The majority of states have passed restriction legislation. C) The state of California, so far, is the only state with legislation in effect. D) Fourteen states have enacted legislation.
The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock. What should the nurse do if the patient's urine output drops to 15 mL for one hour of monitoring?
a. Document the finding. b. Flush the urinary catheter c. Clamp the catheter for 30 minutes. d. Immediately report the drop in urine output.