The nurse is caring for a client diagnosed with leukemia who has just completed a course of radiation therapy and chemotherapy in preparation for a bone marrow transplant. The nurse notices that the client is febrile, has foul smelling urine, and is complaining of urinary frequency and dysuria. What is the priority nursing action?
Request medical prescription for an antibiotic such as gentamicin
Obtain a full set of vital signs and have the client void in a specimen cup
Increase intake of oral fluids such as cranberry juice
Place the client in protective isolation
The Correct Answer is B
A. While antibiotics may be necessary if a UTI is confirmed, requesting a prescription would not be the immediate nursing action. The nurse must first assess the situation thoroughly and obtain necessary diagnostic information before medications can be prescribed.
B. This option is the most appropriate immediate action. Obtaining a full set of vital signs helps assess
the client’s overall condition, including the degree of fever and any signs of systemic infection. Collecting
a urine specimen will facilitate further evaluation, such as a urinalysis and culture, to confirm a UTI and identify the appropriate antibiotic treatment.
C. While increasing fluid intake can help with urinary tract health and dilute the urine, it is not an immediate priority in this situation. The client may need more urgent assessment and possible medical intervention rather than just dietary changes.
D. Although protective isolation may be warranted given the client’s immunocompromised state due to chemotherapy and radiation, it is not the immediate priority based on the current symptoms. The focus should first be on assessing and addressing the potential UTI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. After intravesical therapy, there may be recommendations to avoid sexual activity for a certain period (often 24 hours) to prevent exposure to the medication by a partner. However, the specifics can vary based on the medication used. Twelve hours might not be sufficient depending on the protocol.
B. Self-catheterization is not routinely required unless there is a specific reason (e.g., urinary retention or difficulty voiding). This statement is not relevant to the therapy itself.
C. Urinating in a sitting position can help ensure more complete emptying of the bladder and can be safer, particularly for women. It also may minimize contact with any residual medication in the bladder, which can be a consideration post-infusion.
D. Patients are usually advised to avoid excessive fluid intake immediately before the infusion to prevent bladder distention during the treatment.
Correct Answer is C
Explanation
A. 1500 is 8 hours after 0700, which is too long for the remaining fluid to last.
B. 1200 is 5 hours after 0700, which means there would still be fluid left in the bag at this time.
C. 1100 is exactly 4 hours after 0700, which aligns with our calculation of when the remaining 500 mL will be finished.
D. 0200 is 19 hours after 0700, which is far too late for the IV fluid to last.
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