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NCLEX · Fluid and Electrolyte Imbalances

A post-surgical client has a urine output of 20 mL over the past hour. Normal minimum is 30 mL/hr. What is the LPN's priority action?

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Correct answer

Notify the RN immediately — urine output below 30 mL/hr (oliguria) is a critical finding that may indicate inadequate renal perfusion, hypovolaemia, or acute kidney injury requiring prompt assessment and intervention

  1. A Document and recheck in two hours
  2. B Encourage the client to drink more fluids
  3. C Reassure the client this is normal after surgery
  4. D Notify the RN immediately — urine output below 30 mL/hr (oliguria) is a critical finding that may indicate inadequate renal perfusion, hypovolaemia, or acute kidney injury requiring prompt assessment and intervention

Why this is the answer

OLIGURIA (<30 mL/hr or <0.5 mL/kg/hr): This is a critical assessment finding.

Causes: Hypovolaemia (most common post-surgical — inadequate fluid replacement, haemorrhage); cardiac output reduction (heart failure, MI); renal causes (ATN, contrast nephropathy); obstruction (kinked catheter — check first); PRE-RENAL vs RENAL: Pre-renal oliguria responds to fluids; renal oliguria does not — distinguishing them guides treatment.

Immediate nursing actions: Check catheter for kinks, clots, or position issues (simple fix first); assess vital signs (hypotension + oliguria = volume depletion until proven otherwise); notify RN urgently — this requires medical assessment.

Anticipated orders: IV fluid bolus if pre-renal; renal panel, BMP; strict intake/output.

Pn scope: Assess, check equipment, NOTIFY RN IMMEDIATELY — do not wait; time-sensitive finding.

Source: NCLEX-PN Physiological — Post-op Oliguria, Urinary Output Monitoring

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About this topic: Fluid and Electrolyte Imbalances

Fluid and electrolyte questions cover normal ranges for sodium, potassium, calcium and magnesium, the signs of each imbalance, and the nursing actions and client teaching for dehydration and fluid overload. This is one of 9 PN: Physiological Integrity questions on fluid and electrolyte imbalances, each with a full explanation on a single study page.

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