A nurse in a health clinic is caring for a client. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurse's Notes

0930:

• Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever of 39.3°C (102.8°F) this morning.
• Oriented x-4, answers questions appropriately.
• S1, S2, on auscultation. Lungs clear on auscultation.
• Bowel sounds x 4 quadrants active, denies nausea or vomiting.

0945:

• Request client provide clean-catch urinary specimen for testing.
• Urinalysis results reviewed.

Vital Signs 0930:

• Temperature: 39.3°C (102.8°F)
• Heart rate: 113/min
• Respiratory rate: 24/min
• Blood pressure: 122/68 mm Hg
• Oxygen saturation: 96% on room air

Diagnostic Results 1030:

Urinalysis

• Appearance: Cloudy
• Color: Amber yellow
• Odor: Aromatic
• pH: 8.0 (Reference: 4.6 to 8.0)
• Protein: 6.5 mg/dL (Reference: 0 to 8 mg/dL)
• Specific gravity: 1.035 (Reference: 1.005 to 1.030)
• Leukocyte esterase: Positive
• Nitrites: Present
• Ketones: None
• Bilirubin: None

Choice A reason:
Placing the wasted portion of the controlled substance in the sharp container is not correct. Wasted controlled substances should be disposed of according to specific regulations and facility protocols.
Choice B reason:
Asking a second nurse to record her signature when wasting an unused portion of the controlled substance is not a standard practice. The process for wasting controlled substances usually involves following specific documentation procedures, but this does not necessarily require a second nurse's signature.
Choice C reason:
Over-verifying the count total of the controlled substance after removing the amount needed is not a standard practice. It's important to maintain accurate records and documentation, but additional verification of the count total may not be necessary in this context.
Choice D reason:
Reporting any discrepancy in the count total of the controlled substance after administration is the appropriate action. When administering a controlled substance, it is important to accurately account for the medication before and after administration. Any discrepancy in the count of the controlled substance should be reported and documented according to facility policy. This helps ensure proper tracking and accountability of controlled substances, which is crucial for maintaining patient safety and preventing potential diversion or misuse.

Choice A reason:
Plain yogurt is appropriate for a full-liquid diet as it is a liquid at room temperature and provides nutritional value.
A full-liquid diet consists of foods that are liquid at room temperature and can be easily poured or sipped. It includes clear liquids as well as liquids that are more opaque, like milk-based products and certain blended foods. Among the options provided:
Choice B reason:
Scrambled eggs are not appropriate. Scrambled eggs are not typically considered a part of a full-liquid diet. They have a solid texture and may not be suitable for this specific dietary progression.
Choice C reason:
Oatmeal is inappropriate. Oatmeal is a solid food that does not meet the criteria for a full-liquid diet. It is usually allowed on a soft or regular diet after appropriate postoperative recovery.
Choice D reason:
Applesauce is inappropriate. While applesauce is softer than solid foods, it is not typically included in a full liquid diet. It is more commonly associated with a soft or pureed diet.