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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

A.

urinary frequency, burning on urination, and lower back

B.

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

C.

Appearance: Cloudy

D.

pH: 8.0 (Reference: 4.6 to 8.0)

E.

Leukocyte esterase: Positive

F.

Nitrites: Present

G.

Heart rate: 113/min

H.

Respiratory rate: 24/min

I.

Specific gravity: 1.035 (Reference: 1.005 to 1.030)

J.

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.


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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 B

Explanation

Choice A reason:
Performing percussion over the lower back: While percussion is part of the postural drainage technique, the specific areas to be percussed depend on the client's individualized care plan, which is based on the location of lung segments affected by cystic fibrosis. The nurse should follow the care plan and target the appropriate lung segments for percussion.
Choice B reason:
Covering the area of percussion with a towel is correct. When performing postural drainage with percussion and vibration for a client with cystic fibrosis, it is important to cover the area of percussion with a towel. This helps protect the client's skin and prevent discomfort or injury during the procedure. The towel acts as a barrier between the nurse's hand and the client's skin, allowing for effective percussion while minimizing friction and pressure

Choice Creason:
Scheduling postural drainage after meals: Postural drainage is ideally performed before meals or at least 1-2 hours after meals to avoid potential discomfort or vomiting due to the positioning and movement during the procedure.
Choice Dreason:
Instructing the client to exhale quickly during vibration: Vibration is typically performed during the client's exhalation phase, but the instruction should focus on slow, controlled exhalation rather than quick exhalation.

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