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:
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.

Choice A reason:
Powdered gloves are more likely to release latex particles into the air, which can increase the risk of exposure for a client with a latex allergy. Therefore, using non-powdered gloves is recommended.
Choice B reason:
Scheduling the client as the first surgical procedure of the day is the appropriate action because it can help minimize the risk of latex exposure. This is because latex particles released into the air during previous surgeries can settle in the surgical environment, increasing the risk for individuals with latex allergies. By scheduling the client's surgery as the first procedure, the likelihood of exposure to residual latex particles is reduced.
Choice C reason:
Removing the stopcocks from IV tubing does not directly address the risk of latex exposure in a surgical setting.
Choice D reason:
Cleansing stoppers with povidone-iodine is a good practice for infection control but does not specifically address the risk of latex exposure for a client with a latex allergy during surgery.