Question

A nurse is caring for a group of clients on a unit. Which of the following assessment findings should the nurse recognize as the priority to report to the charge nurse?

Option 1: A client who has heart failure and 2+ edema of the lower extremities.

Option 2: A client who is 2 days postoperative and has a urine output of 20 mL/hr.

Option 3: A client who started taking verapamil and has a heart rate of 75/min.

Option 4: A client who is receiving morphine and reports nausea.

Answer 1

The priority assessment finding to report is the postoperative client with a urine output of 20 mL/hr, indicating potential acute renal failure or obstruction, requiring immediate attention and further diagnostic measures.

Step-by-step explanation:

The assessment finding that should be a priority to report to the charge nurse is a client who is 2 days postoperative and has a urine output of 20 mL/hr. This low urine output may be an indication of acute renal failure or obstructed urinary flow, which can be the result of several underlying issues such as medication interfering with normal bladder emptying, kidney stones, or benign prostatic hypertrophy. Acute renal failure requires immediate attention to prevent further complications, and it can be diagnosed with elevated creatinine or blood urea nitrogen levels, and if oliguria is present (a urine production of <0.5 ml/kg body weight for 6 hours). Ultrasound can be utilized to rule out obstruction if the cause of low urine output is not apparent.