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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

urinary frequency, burning on urination, and lower back

developed a fever of 39.3°C (102.8°F) this morning

Appearance: Cloudy

pH: 8.0 (Reference: 4.6 to 8.0)

Leukocyte esterase: Positive

Nitrites: Present

Heart rate: 113/min

Respiratory rate: 24/min

Specific gravity: 1.035 (Reference: 1.005 to 1.030)

Blood pressure: 122/68 mm Hg

Answer and Explanation

The Correct Answer is ["A","B","C","E","F"]

Client Symptoms:

Urinary Symptoms: The client reports a 2-day history of urinary frequency, burning on urination, and both lower back and suprapubic pain.
Fever: The client states they developed a fever this morning.

Urinalysis Results:

Appearance: Cloudy urine.
Leukocyte Esterase: Positive, indicating the presence of white blood cells.
Nitrites: Present, suggesting bacterial infection.

Assessment:

These findings strongly suggest a Urinary Tract Infection (UTI). The combination of urinary symptoms, fever, and urinalysis results supports this diagnosis. The nurse should promptly report these findings to the healthcare provider to ensure timely intervention.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A reason:
False imprisonment is the correct answer because it occurs when a person intentionally restricts the freedom of movement of another person without proper consent or legal justification. In this scenario, the AP is threatening to place the client in restraints against their will if they do not comply with bed rest. This action is a violation of the client's rights and constitutes false imprisonment.
Choice B reason:
Defamation of character is incorrect: Defamation involves making false statements about someone that harm their reputation. It doesn't apply to this scenario.
Choice C reason:
Battery is incorrect: Battery involves intentional harmful or offensive physical contact with another person without their consent. There is no indication of physical contact in this situation.
Choice D reason:
Assault is incorrect. Assault refers to the intentional threat or act that causes fear of imminent harmful or offensive contact. While there is a threat implied in this scenario, the threat is of false imprisonment rather than physical harm, making false imprisonment a more accurate description of the tort.

A. Percuss all four quadrants of the abdomen to measure sound quality. B. Provide adequate lighting to inspect the abdomen. C. Listen to the abdominal arteries using the bell of a stethoscope. D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen. E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.

Correct Answer is B, C, E, D, A

Explanation

B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.

C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.

E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.

D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort.

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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

Vital Signs 0930:

Diagnostic Results 1030:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B, C, E, D, A

Explanation

A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?

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A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

A nurse is reviewing the medical record for a newly admitted client. Which of the following laboratory values should the nurse report to the provider?

A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the Injection?

Nurse's Notes

Vital Signs 0930:

Diagnostic Results 1030:

A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?