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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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

A. Place the wasted portion of the controlled substance in the sharp container. B. Ask a second nurse to record her signature when wasting any unused portion of the controlled substance. C. Verify the count total of the controlled substance after removing the amount needed. D. Report any discrepancy in the count total of the controlled substance after administration.

Correct Answer is C

Explanation

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:
Verifying the count total of the controlled substance after removing the amount needed is the appropriate action. When administering a controlled substance, it is crucial to maintain accurate accountability of the medication. This includes verifying the count total of the controlled substance before and after removing the amount needed for administration. This step helps ensure proper documentation, prevent errors, and maintain appropriate control over controlled substances.
Choice D reason:
Reporting any discrepancy in the count total of the controlled substance after administration is important, but it should be done as a separate step from verifying the count total before administration. Discrepancies should be reported according to facility policy to ensure proper investigation and resolution.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

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?

A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is providing teaching for a client who is scheduled for an allogeneic stem cell transplant. Which of the following information should the nurse include?

A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first?

A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? (Select all that apply.)

A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?