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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
A. Place the tourniquet below the proposed insertion site.
When preparing to insert an IV catheter, placing the tourniquet below the proposed insertion site helps facilitate venous distension, making it easier to locate and access a suitable vein for catheter insertion.
Choice B reason:
Placing the extremity in a dependent position (lower than the heart) can increase venous pressure and make it more difficult to insert the catheter.
Choice C reason:
Choosing the most proximal site on the extremity is not always necessary or appropriate. Veins distal to the proposed insertion site should be considered first, as they tend to be smaller and less accessible.
Choice D reason:
Applying a cool compress is not typically done before IV catheter insertion. It might cause vasoconstriction and make it more difficult to access a suitable vein.
Correct Answer is C
Explanation
Choice A reason:
The cephalic vein on the back of the right hand is incorrect because it might still involve the same arm as the mastectomy site, and it is important to avoid this side.
Choice B reason:
The radial vein on the left wrist is incorrect because it is not on the opposite side of the mastectomy and could increase the risk of lymphedema.
Choice C reason:
The basilic vein in the right antecubital fossa is the appropriate answer. When inserting an IV catheter for a client who has undergone a right mastectomy, it is generally advisable to avoid the arm on the same side as the mastectomy due to the risk of lymphedema and impaired lymphatic drainage. The basilic vein in the right antecubital fossa (the inner bend of the right elbow) would be a suitable choice in this case, as it is on the opposite side of the mastectomy.
Choice D reason:
The cephalic vein in the left distal forearm is on the same side as the mastectomy and should be avoided to reduce the risk of complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today