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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

A.

urinary frequency, burning on urination, and lower back

B.

developed a fever of 39.3°C (102.8°F) this morning

C.

Appearance: Cloudy

D.

pH: 8.0 (Reference: 4.6 to 8.0)

E.

Leukocyte esterase: Positive

F.

Nitrites: Present

G.

Heart rate: 113/min

H.

Respiratory rate: 24/min

I.

Specific gravity: 1.035 (Reference: 1.005 to 1.030)

J.

Blood pressure: 122/68 mm Hg

Answer and Explanation

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.


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Related Questions

Correct Answer is C

Explanation

Choice A reason:
Placing the wasted portion of the controlled substance in the sharp container is not correct. Wasted controlled substances should be disposed of according to specific regulations and facility protocols.
Choice B reason:
Asking a second nurse to record her signature when wasting an unused portion of the controlled substance is not a standard practice. The process for wasting controlled substances usually involves following specific documentation procedures, but this does not necessarily require a second nurse's signature.
Choice C reason:
Verifying the count total of the controlled substance after removing the amount needed is the appropriate action. When administering a controlled substance, it is crucial to maintain accurate accountability of the medication. This includes verifying the count total of the controlled substance before and after removing the amount needed for administration. This step helps ensure proper documentation, prevent errors, and maintain appropriate control over controlled substances.
Choice D reason:
Reporting any discrepancy in the count total of the controlled substance after administration is important, but it should be done as a separate step from verifying the count total before administration. Discrepancies should be reported according to facility policy to ensure proper investigation and resolution.

Correct Answer is ["A","B","C","E","F"]

Explanation

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.

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