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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B) Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C) Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D) Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.
Correct Answer is C
Explanation
A. Increased libido is unlikely due to the loss of testosterone production.
B. Hypoglycemia is not directly related to the surgical procedure.
C. Bilateral orchiectomy, the surgical removal of both testicles, results in a sudden decrease in testosterone levels, which can lead to symptoms such as hot flashes, similar to those experienced during menopause.
D. Increased muscle mass is associated with testosterone production, which would decrease following bilateral orchiectomy.
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