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. This choice is not relevant to reducing the risk of cervical cancer. Hormone replacement therapy (HRT) is primarily used to manage symptoms of menopause and does not have a protective effect against cervical cancer.
B. While colposcopy is a diagnostic procedure used to evaluate abnormal cervical findings, it is not a routine screening method. The primary screening method for cervical cancer is the Pap test (Papanicolaou test) combined with HPV (human papillomavirus) testing. Colposcopy is usually performed after an abnormal Pap test result, not on a yearly basis for general screening.
C. Utilizing safer sex methods, such as consistent use of condoms and reducing the number of sexual partners, can help decrease the risk of acquiring HPV, which is the primary cause of cervical cancer. Promoting safe sexual practices is a key component of cervical cancer prevention.
D. This choice is not effective for reducing the risk of cervical cancer. While vaginal ultrasounds may be used for various gynecological assessments, they are not a screening tool for cervical cancer and do not reduce the risk of developing the disease.
Correct Answer is D
Explanation
A. These are behavioral changes that may occur after a stroke, but they are not directly related to motor loss.
B. Hemiparesis is weakness on one side of the body, but in this case, the client is experiencing motor loss on the right side. Apraxia is the inability to perform purposeful movements, which can also occur after a stroke, but it is not a direct manifestation of motor loss.
C. Homonymous hemianopia is the loss of vision in half of the visual field on the same side as the stroke. Diplopia is double vision. While these are both common symptoms of stroke, they are not related to motor loss.
D. A left-sided stroke typically results in motor loss on the right side of the body. This is because the left side of the brain controls the right side of the body. Additionally, ataxia, which is a lack of coordination, is a common symptom of stroke.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.