The nurse is caring for an elderly female client who has an indwelling catheter. Which data in the assessment warrants notification of the health care provider?
Change in mental status
Vital signs: T-98, P- 90, RR- 20, BP-142/88.
Client states, "No discomfort or pain."
Urine is cloudy with sediment
The Correct Answer is A
A. This is a significant finding that warrants immediate notification. Changes in mental status in elderly patients can indicate a variety of issues, including infection (such as a urinary tract infection), dehydration, or other acute illnesses. Given that elderly patients are at higher risk for delirium and other cognitive changes, this finding should be taken seriously.
B. These vital signs are largely within normal limits for an elderly patient. While the blood pressure is on the higher side, the heart rate and respiratory rate are within acceptable ranges. Therefore, this does not warrant immediate notification unless other symptoms are present.
C. This statement is reassuring and suggests that the client is not experiencing complications related to the indwelling catheter, such as infection or obstruction. It does not indicate any need for immediate notification of the provider.
D. Cloudy urine with sediment can be indicative of a urinary tract infection (UTI) or other complications related to the indwelling catheter. While this finding is concerning and may require further evaluation, it is not as urgent as a change in mental status. It should still be reported to the healthcare provider but may not necessitate immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The elevated pH and decreased PaCO2 indicate that the respiratory system is causing alkalosis, typically due to hyperventilation (excessive breathing).
B. Metabolic alkalosis would be indicated by a high pH with a normal or high HCO3. Since the HCO3 level is normal and the PaCO2 is low, this does not fit the picture of metabolic alkalosis.
C. Respiratory acidosis would be characterized by a low pH and an elevated PaCO2 due to inadequate ventilation and accumulation of carbon dioxide. Here, the pH is high, and the PaCO2 is low.
D. Metabolic acidosis would be indicated by a low pH with a low HCO3. In this case, the pH is high, and the HCO3 is normal.
Correct Answer is C
Explanation
A. This response shows some awareness but does not indicate a sufficient understanding of the risks. Straight razors can pose a significant risk of cuts and bleeding, especially in a patient who has received t- PA, which can increase the likelihood of bleeding.
B. This response suggests a misunderstanding. Using multiple razor blades does not inherently reduce the risk of bleeding and could increase the chance of cuts or nicks. This response does not indicate an appropriate understanding of safety precautions related to t-PA.
C. This response indicates an understanding of safety precautions. Electric razors are safer for clients who are at risk of bleeding because they do not have sharp blades that can easily cause cuts. This choice minimizes the risk of injury while allowing for personal grooming.
D. While disposable razors may seem convenient, they still carry a risk of cuts and bleeding. This response does not reflect a full understanding of the precautions necessary for a client who has received t-PA, as it does not prioritize safety in the same way that using an electric razor does.
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