A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

Temperature 37.3° C (99.1° F)

WBC Count 9,000/mm3

Changed mental status

Diminished reflexes

Answer and Explanation

The Correct Answer is C

A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.

A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.

B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.

D: Diminished reflexes are not typically associated with a bladder infection.

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Correct Answer is C

Explanation

The correct answer is choice C. Implement droplet precautions. Streptococcal pharyngitis is a highly contagious infection caused by group A beta-hemolytic streptococcus. Droplet precautions are the appropriate precautionary measures to prevent the spread of the infection. This includes placing the client in a private room or with a client with the same infection, wearing a mask or respirator, and using proper hand hygiene. Option A is incorrect because negative airflow rooms are not required for clients with streptococcal pharyngitis. Option B is incorrect because throat cultures should be obtained before the initial dose of antibiotics. Option D is incorrect because fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

Option A - Negative airflow rooms are used for airborne illnesses like tuberculosis.

Option B - Throat culture should be obtained before the initial dose of antibiotics.

Option D - Fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.

A. Elevate the head of the client's bed for 1 hr after the feeding. B. Administer the feeding solution at a cold temperature. C. Rotate the jejunostomy tube once per day D. Flush the tube with 90 mL of sterile water before and after the feeding.

Correct Answer is A

Explanation

Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux.

Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea.

Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site.

Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.

The explanation for why the other choices are not answered: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.

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A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in developing the plan of care for a client with streptococcal pharyngitis. What is an appropriate action to include in the plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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