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 B

Explanation

A) Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B) A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C) Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D) Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.

A. "The elastic bandage will prevent a postoperative wound infection." B. "The elastic bandage will prevent excessive edema." C. "The elastic bandage will keep you from seeing the surgical site." D. "The elastic bandage will keep the sutures from loosening."

Correct Answer is B

Explanation

A. While wound infection prevention is important, the elastic bandage primarily addresses edema control.
B. Maintaining an elastic bandage around the residual limb helps to compress soft tissues and minimize edema, promoting healing and aiding in the shaping of the residual limb for future prosthesis fitting.
C. The purpose of the elastic bandage is not related to preventing the client from seeing the surgical site.
D. The elastic bandage is not primarily used to secure sutures; its main purpose is edema control.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

Correct Answer is B

Explanation

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

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