A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?

Question

Quizplus · Accepted Answer

Urine output of less than 30 mL/hr may indicate low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). Given this client's heart failure, low urine output is likely due to decreased cardiac function and buildup of fluid in the lungs. The nurse should assess the lung sounds for crackles and report to the HCP, who can prescribe loop diuretics. (Option B) The client with heart failure is at risk for fluid overload. Fluids should not be encouraged before consulting with the HCP to determine the cause of decreased urine output. If this client had dehydration, fluids would be encouraged. (Options C and D) Always assess the client first, and then report to the HCP. A diuretic may be prescribed by the HCP if crackles and dyspnea are present. Educational objective: Decreased urine output of <30 mL/hr could be due to low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). Always assess the client first, and then report to the HCP.

A Client Diagnosed with Heart Failure Has an 8-Hour Urine