A nurse in a health clinic is caring for a client. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.
Nurse's Notes
0930:
- Client reports 2-day history of urinary frequency, burning on urination, and lower back and suprapubic pain. States developed a fever of 39.3°C (102.8°F) this morning.
- Oriented x-4, answers questions appropriately.
- S1, S2, on auscultation. Lungs clear on auscultation.
- Bowel sounds x 4 quadrants active, denies nausea or vomiting.
0945:
- Request client provide clean-catch urinary specimen for testing.
- Urinalysis results reviewed.
Vital Signs 0930:
- Temperature: 39.3°C (102.8°F)
- Heart rate: 113/min
- Respiratory rate: 24/min
- Blood pressure: 122/68 mm Hg
- Oxygen saturation: 96% on room air
Diagnostic Results 1030:
Urinalysis
- Appearance: Cloudy
- Color: Amber yellow
- Odor: Aromatic
- pH: 8.0 (Reference: 4.6 to 8.0)
- Protein: 6.5 mg/dL (Reference: 0 to 8 mg/dL)
- Specific gravity: 1.035 (Reference: 1.005 to 1.030)
- Leukocyte esterase: Positive
- Nitrites: Present
- Ketones: None
- Bilirubin: None
urinary frequency, burning on urination, and lower back
developed a fever of 39.3°C (102.8°F) this morning
Appearance: Cloudy
pH: 8.0 (Reference: 4.6 to 8.0)
Leukocyte esterase: Positive
Nitrites: Present
Heart rate: 113/min
Respiratory rate: 24/min
Specific gravity: 1.035 (Reference: 1.005 to 1.030)
Blood pressure: 122/68 mm Hg
The Correct Answer is ["A","B","C","E","F"]
Client Symptoms:
- Urinary Symptoms: The client reports a 2-day history of urinary frequency, burning on urination, and both lower back and suprapubic pain.
- Fever: The client states they developed a fever this morning.
Urinalysis Results:
- Appearance: Cloudy urine.
- Leukocyte Esterase: Positive, indicating the presence of white blood cells.
- Nitrites: Present, suggesting bacterial infection.
Assessment:
- These findings strongly suggest a Urinary Tract Infection (UTI). The combination of urinary symptoms, fever, and urinalysis results supports this diagnosis. The nurse should promptly report these findings to the healthcare provider to ensure timely intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a."OJ" for orange juice is not recommended. While it might seem straightforward, "OJ" could be confused with "oj" or other abbreviations, leading to potential confusion. It's better to write out "orange juice."
b."SS" for sliding scale is not recommended" could be misinterpreted or confused with other meanings. It's safer to write out "sliding scale."
c.SQ is commonly mistaken as “5 every”.Use SUBQ (all UPPERCASE letters, without spaces or periods between letters), or subcutaneous(ly).
d.This is a commonly accepted abbreviation in medical documentation, meaning bathroom privileges.
Correct Answer is C
Explanation
Choice A reason:
Protective precautions are not necessary because they (also known as reverse isolation) are used for immunocompromised clients to protect them from potential pathogens carried by healthcare workers or visitors.
Choice B reason:
Droplet precautions are not necessary because they are used for infections spread through larger respiratory droplets, like influenza or pertussis.
Choice C reason:
Airborne precautions should be implemented by the nurse. Tuberculosis (TB) is primarily transmitted through the airborne route, as the bacteria that cause TB can be suspended in the air as tiny particles (droplet nuclei) when an infected person coughs, sneezes, speaks, or sings. These particles can be inhaled by others, leading to the potential transmission of the disease.
Choice D reason:
Contact precautions are not necessary because they are used for infections that are transmitted through direct contact with the client or contaminated surfaces, such as MRSA (Methicillin-resistant Staphylococcus aureus) or C. difficile.
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