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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 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.

Correct Answer is A

Explanation

A) Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B) Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C) Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D) Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.

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