Difficulty: Medium
Average Score: 83%
Full-length
Passage / Scenario
The patient has been receiving 2500 ml of IV fluid and 300 to 400 ml of oral intake daily for 2 days. The patient's urine output has been decreasing and now has been less than 40 ml per hour for the past 3 hours.The nurse should immediately:
Correct answer
B
Rationale
The imbalance in intake and output, with decreasing urinary output, may indicate renal failure or fluid overload, potentially leading to congestive heart failure. Assessing breath sounds and vital signs is the first step.