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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.

Exhibits
Findings 12 hr later: Unrelated to diagnosis /Indication of potential improvement / Indication of potential worsening of condition

A.

Oxygen saturation 96% at 2 L/min via nasal cannula

B.

Disoriented to person, place, and time

C.

Blood pressure 100/50 mm Hg

D.

Hct 45%

E.

Pink-tinged urine

F.

Butterfly rash

Answer and Explanation

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 ["B","C","D"]

Explanation

A) Infusing 0.9% sodium chloride is incorrect as it's not appropriate for TPN administration.
B) Obtaining the client's weight daily helps to monitor nutritional status and adjust TPN accordingly.
C) Monitoring serum blood glucose is essential due to the high glucose content in TPN, which can lead to hyperglycemia.
D) Verifying the solution with another RN prior to infusion is a safety measure to ensure the correct solution and dosage.
E) Increasing the rate of infusion if administration is delayed may lead to complications and is not appropriate without medical orders.

Correct Answer is C

Explanation

A) Distended jugular veins are associated with fluid overload, not dehydration.

B) Pitting, dependent edema is also associated with fluid overload, not dehydration.

C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.

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