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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","H"]
Explanation
A. This prescription addresses hypokalemia. Potassium chloride is administered intravenously to help normalize potassium levels within the desired range. However, in this case the patient’s potassium is 5.5 hence does not require potassium chloride.
B. The client has mild hyperkalemia; hence, continuous cardiac monitoring is prudent to detect any potential arrhythmias or changes in cardiac status. However, the priority interventions are insulin therapy, hydration, and urinary catheter insertionto monitor input and output.
C. Subcutaneous insulin administration may be appropriate for clients with diabetes mellitus, but in this case, the client's blood glucose level is critically high, and they may be experiencing diabetic ketoacidosis (DKA), which requires rapid correction. Subcutaneous insulin administration would not provide the prompt and aggressive treatment required for DKA.
D. This prescription addresses the client's hyperglycemia and acidosis indicated by the blood glucose level of 468 mg/dL and pH of 7.30, respectively. Continuous intravenous insulin infusion is the standard treatment for diabetic ketoacidosis (DKA) to lower blood glucose levels and correct acidosis.
E. This prescription addresses the client's dehydration indicated by the elevated blood glucose level, decreased blood pressure, and slight tenting of the skin. Intravenous fluid resuscitation with 0.9% sodium chloride is initiated to restore intravascular volume and correct electrolyte imbalances.
F. Administering D5W intravenously is contraindicated in the setting of hyperglycemia and diabetic ketoacidosis (DKA) because it would exacerbate the already elevated blood glucose levels. D5W contains glucose and would further increase blood glucose levels, worsening the client's condition.
G. While monitoring blood glucose levels is important for clients with diabetes, checking it every 4 hours is not sufficient in this scenario, especially given the client's markedly elevated blood glucose level of 468 mg/dL and symptoms suggestive of diabetic ketoacidosis (DKA). Therefore, blood glucose levels should be monitored at least hourly.
H. Monitoring urine output is important in clients with diabetes and dehydration. Therefore, inserting an indwelling urinary catheter is important in this scenario.
Correct Answer is A
Explanation
A. The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B. Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C. Administering corticosteroids is not indicated based on the client's symptoms and situation.
D. Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.
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