Question

The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is:

a) 40 mL/hour
b) 20 mL/hour
c) 80 mL/hour
d) 60 mL/hour

Answer 1

The most concerning urine output for a client diagnosed with hypovolemic shock is 20 mL/hour, indicating oliguria and potential severe kidney impairment that necessitates immediate medical attention.

Step-by-step explanation:

The nurse monitoring a client diagnosed with hypovolemic shock is most concerned if the client's urine output is 20 mL/hour. Hypovolemic shock results in the circulatory system's failure to maintain adequate blood flow, leading to a dramatic fall in urine output. For an adult in shock, a urine output of less than 1 mL/kg body weight/hour is cause for concern, and the minimal normal urine output in a healthy adult should be about 500 mL/day to eliminate waste. Output below this level indicates the kidneys are not sufficiently excreting metabolic wastes, compromising organ function. This condition is known as oliguria. Therefore, an hourly output of 20 mL could signify severe impairment in kidney function, requiring immediate medical intervention to prevent further organ damage or death.

Answer 2

The nurse would be most concerned if the client's urine output is 20 mL/hour, as this indicates worsening hypovolemia in the case of hypovolemic shock.The correct option is B.

Step-by-step explanation:

The nurse in this situation is monitoring the hourly urine output of a client diagnosed with hypovolemic shock. The nurse would be most concerned if the client's urine output is b) 20 mL/hour.

In hypovolemic shock, the body's blood volume is significantly reduced, leading to inadequate tissue perfusion. As urine output decreases, it indicates a decrease in renal blood flow and compromised kidney function. A urine output of 20 mL/hour is very low and could indicate worsening hypovolemia.