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 ["69"]
Explanation
To calculate the daily protein requirement for the client, first convert the weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds.
The client's weight in kilograms is 190 lb divided by 2.2, which equals approximately
86.36 kg.
Then, multiply the weight in kilograms by the recommended dietary allowance (RDA) of protein, which is 0.8 g/kg. So, 86.36 kg multiplied by 0.8 g/kg equals about
69.09 g. Rounding to the nearest whole number, the client should receive 69 grams of protein daily.
Correct Answer is D
Explanation
A. While pain assessment is important, ensuring airway patency takes priority over pain assessment in a client who has received sedation.
B. Monitoring temperature is important but is not the priority in this scenario.
C. Warmth of extremities is not as critical as assessing the airway.
D. Gag reflex assessment is essential to evaluate the client's ability to protect their airway and prevent aspiration, especially after receiving sedation.
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