A nurse is caring for an older adult client who was admitted with a urinary tract infection.
Findings upon admission:
The nurse is assessing the client 12 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.
Oxygen saturation 96% at 2 L/min via nasal cannula
Disoriented to person, place, and time
Blood pressure 100/50 mm Hg
Hct 45%
Pink-tinged urine
Butterfly rash
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}
A) An increase in oxygen saturation to 96% at a reduced oxygen flow rate indicates potential improvement in respiratory function, which can be a positive sign of recovery from a UTI.
B) Disorientation to person, place, and time suggests a potential worsening of the condition, as UTIs can cause confusion, especially in older adults and those with dementia.
C) A drop in blood pressure to 100/50 mm Hg could indicate potential worsening, as it may suggest dehydration or sepsis, both of which can complicate a UTI.
D) A decrease in hematocrit (Hct) to 45% is within the normal range and could indicate an improvement if previously elevated due to dehydration.
E) Pink-tinged urine may indicate the presence of blood, a sign of potential worsening, as it could suggest a more severe infection or other complications.
F) A butterfly rash is not typically associated with a UTI and may be unrelated to the current diagnosis; in this scenario it is related to the patient’s history of systemic lupus erythematosus.
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Related Questions
Correct Answer is C
Explanation
A) This is not a standard intervention for bladder spasms post-TURP.
B) Securing the urinary catheter to the abdomen does not address the immediate issue of potential catheter blockage.
C) Performing an intermittent bladder irrigation using sodium chloride is appropriate in this case. This is because bladder spasms and a scant amount of fluid in the urinary drainage bag may indicate a blockage in the catheter. Intermittent bladder irrigation can help to remove any clots or debris that may be causing the blockage.
D) Encouraging the client to urinate is not applicable as the client cannot urinate normally due to the surgery.
Correct Answer is B
Explanation
A) While wearing an N95 respirator may be necessary for certain infections, it is not a routine precaution for clients in protective isolation.
B) Ensuring the client's room has positive-pressure airflow helps prevent the entry of airborne pathogens into the room, reducing the risk of infection for the immunocompromised client.
C) Using disposable plates and utensils helps reduce the risk of cross-contamination and infection transmission but is not directly related to airborne infection control.
D) Monitoring the client's temperature is important for assessing for signs of infection, but it does not directly prevent infection transmission in the same way as positive-pressure airflow.
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