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 D
Explanation
A. This nurse is already exposed to a significant amount of radiation and should not be assigned to care for another client with an internal radiation implant.
B. Pregnant women should avoid exposure to radiation. This nurse should not be assigned to care for a client with an internal radiation implant.
C. While this nurse has experience with internal radiation, she is still exposed to radiation. It is preferable to assign a nurse who has no prior exposure to internal radiation.
D. This nurse has no prior exposure to internal radiation and is therefore the best candidate to provide care to the client.
Correct Answer is C
Explanation
A. This test is used to measure the level of prolactin, a hormone that stimulates milk production. It is not relevant for cervical cancer screening.
B. This test involves taking a sample of tissue from the lining of the uterus. It is used to diagnose endometrial cancer, not cervical cancer.
C. The Papanicolaou test, commonly known as a Pap smear, is the standard screening test for cervical cancer. It involves collecting cells from the cervix to detect any precancerous changes or cervical cancer itself. This is the correct answer, as it directly relates to cervical cancer screening.
D. This test uses sound waves to create images of the vagina and cervix. It can be used to evaluate the cervix for abnormalities, but it is not as sensitive as a Pap test for detecting cervical cancer.
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