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

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

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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Correct Answer is C

Explanation

A) Keeping the client's knees in a flexed position, is incorrect because prolonged immobility and knee flexion can increase the risk of VTE by impeding venous return.
B) Massaging the client's legs, is not recommended as it may dislodge a potential clot that has formed, leading to a thromboembolic event.
C) This exercise can help promote blood circulation and prevent clot formation without exerting excessive pressure on the surgical site.
D) Adequate hydration is essential for preventing blood clots; dehydration can lead to hemoconcentration and increased risk of thrombosis.

A. "You will need to take an antiviral medication for 6 months." B. "You will need cryotherapy for 1 to 2 weeks," C. "You will need three follow-up blood tests within a 24-month period." D. "You will need to be monitored for 15 minutes after receiving each medication dose."

Correct Answer is C

Explanation

A. Syphilis is a bacterial infection, so antiviral medication is not appropriate.

Treatment typically involves antibiotics, such as penicillin.

B. Cryotherapy is not a standard treatment for primary syphilis. Antibiotics are the primary treatment.

C. This is in line with the treatment guidelines for syphilis, which involve antibiotic therapy and follow-up testing to ensure the infection is fully resolved. The tests are done at 3, 6, and 12 months after completion of treatment.
D. Monitoring after medication doses may be necessary for certain medications but is not specifically indicated for primary syphilis.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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