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. While applying heat may help alleviate discomfort, it is not the primary recommendation for managing epididymitis. The treatment often involves rest, elevation of the scrotum, and possibly cold packs rather than heat. Therefore, while this statement may reflect some understanding, it is not the best indicator of comprehensive knowledge about managing epididymitis.
B. While some mild cases may improve spontaneously, most cases of epididymitis require treatment, especially if they are caused by infections, which are common. Untreated epididymitis can lead to complications, so this statement does not reflect an accurate understanding of the condition.
C. If epididymitis is caused by a sexually transmitted infection (STI), it is important that sexual partners be evaluated and treated as well to prevent reinfection. This indicates a proper understanding of the implications of the condition, particularly in the context of STIs.
D. It seems to reference concerns related to radiation therapy, which is unrelated to the management or understanding of epididymitis. This indicates a lack of focus on the current diagnosis and its implications.
Correct Answer is A
Explanation
A. One of the most common and concerning symptoms of uterine (endometrial) cancer is abnormal vaginal bleeding, particularly postmenopausal bleeding. Any bleeding after menopause is considered abnormal and can be an indicator of uterine cancer, warranting further investigation.
B. While a malodorous vaginal discharge can occur due to infections or other gynecological issues, it is not a primary symptom of uterine cancer. Uterine cancer more commonly presents with bleeding rather than discharge.
C. While some women with advanced uterine cancer may experience pelvic pain or pain during intercourse (dyspareunia), this symptom is not as characteristic or early in the disease process. It is more associated with conditions like endometriosis or pelvic inflammatory disease.
D. This is not a typical manifestation of uterine cancer. While vulvar swelling may be seen in cases of vulvar cancer or infections, it is not a common symptom associated with uterine cancer specifically. Symptoms related to uterine cancer primarily focus on abnormal bleeding.
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