A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?
Hypothermia
Referred pain in the right shoulder
Confusion
Orange-colored urine
The Correct Answer is C
Choice c: Confusion is a finding that the nurse should anticipate in an older adult client who has cystitis, which is inflammation of the bladder caused by a bacterial infection. Confusion can be a sign of sepsis or delirium, which are common complications of urinary tract infections in older adults.
Choice a is not correct because hypothermia is not a finding that the nurse should anticipate in an older adult client who has cystitis. Hypothermia can occur in older adults due to impaired thermoregulation, but it is not related to cystitis.
Choice b is not correct because referred pain in the right shoulder is not a finding that the nurse should anticipate in an older adult client who has cystitis. Referred pain in the right shoulder can indicate gallbladder disease, but it is not related to cystitis.
Choice d is not correct because orange-colored urine is not a finding that the nurse should anticipate in an older adult client who has cystitis. Orange-colored urine can be caused by certain medications, foods, or dehydration, but it is not related to cystitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Keeping both arms below the level of the client's heart can increase venous pressure and fluid accumulation in the affected arm, which can lead to lymphedema.
Choice B reason: After a mastectomy, it’s important to avoid procedures like blood draws, injections, or blood pressure measurements on the side where the surgery was performed to prevent lymphedema. Therefore, using the client’s left arm for blood samples is a preventive measure.
Choice C reason: Obtaining blood pressure readings using the client's right arm is an incorrect action that can increase lymphatic fluid accumulation and impair circulation in the affected arm.
Choice D reason: Limiting range-of-motion exercises with the affected arm is an incorrect action that can decrease lymphatic drainage and increase swelling in the affected arm. The nurse should encourage the client to perform gentle exercises, such as squeezing a soft ball or raising and lowering the arm, to promote lymphatic flow and prevent stiffness.
Correct Answer is A
Explanation
Choice A reason: 0.9% sodium chloride or normal saline is the only solution that should be administered with PRBCs, as it has an isotonic osmolarity and pH that are compatible with blood products and can prevent hemolysis or clotting.
Choice B reason: Dextrose 5% in water or D5W should not be administered with PRBCs, as it has a hypotonic osmolarity that can cause hemolysis or rupture of red blood cells due to osmotic pressure.
Choice C reason: Lactated Ringer's or LR should not be administered with PRBCs, as it contains calcium and lactate that can interfere with blood coagulation and cause clotting or embolism.
Choice D reason: Dextrose 5% in 0.45% sodium chloride or D5½NS should not be administered with PRBCs, as it has a hypotonic osmolarity that can cause hemolysis or rupture of red blood cells due to osmotic pressure.
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