A client presents to the emergency department with complaints of urinary frequency, dysuria, and fever. Which of the following orders should the nurse carry out first?
Prepare the client for a CT scan
Begin broad spectrum antibiotics
Insert a Foley catheter
Obtain samples for urine culture and urinalysis
The Correct Answer is D
A. Prepare the client for a CT scan is not the first priority in this case. A CT scan might be considered if there is suspicion of complications like a kidney stone or abscess, but it is not the first intervention.
B. Begin broad spectrum antibiotics could be considered if a urinary tract infection (UTI) is suspected, but obtaining urine samples for culture and urinalysis is necessary first to confirm the diagnosis and guide antibiotic therapy.
C. Insert a Foley catheter is not indicated unless the patient is unable to void or there is a need for continuous monitoring of urine output, but it is not the first step.
D. Obtain samples for urine culture and urinalysis is the first step to confirm the diagnosis of a urinary tract infection (UTI) and determine the appropriate treatment. This will help guide the selection of antibiotics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Chocolate and peppermint can relax the lower esophageal sphincter, worsening GERD symptoms. These should be avoided.
B. Oatmeal with banana slices is a good choice because it is low in fat and acid, which helps prevent GERD symptoms. Bananas are also a non-acidic fruit that is generally well-tolerated.
C. Spaghetti with tomato sauce contains acidic ingredients that can irritate the esophagus and worsen GERD symptoms.
D. A cheeseburger with grilled onions is high in fat, which can delay gastric emptying and increase reflux. Onions are also a known trigger for GERD symptoms.
Correct Answer is B
Explanation
A. A urine output of 32 mL/hour is slightly below the normal threshold (30 mL/hour) but does not indicate an immediate threat requiring intervention.
B. Confusion and disorientation are signs of severe hyponatremia, which can lead to cerebral edema and life-threatening complications such as seizures or coma. This finding requires immediate intervention to prevent worsening neurological impairment.
C. A blood pressure of 106/82 is within an acceptable range and does not indicate a critical issue in this context.
D. Bilateral 2+ pedal edema is not uncommon in elderly clients and does not directly indicate a severe complication of hyponatremia requiring immediate action.
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