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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

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

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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:
Discarding the needle in a puncture-proof container is the correct action to be taken. After administering an injection, the nurse should immediately dispose of the needle in a puncture-proof container. This helps prevent needlestick injuries and ensures proper disposal of sharp objects.
Choice B reason:
Removing the needle from the syringe is inappropriate because it could increase the risk of a needlestick injury. Needles should be discarded as a unit with the syringe.
Choice C reason:
Placing the needle on the bedside table is not a safe practice and can lead to accidental needlestick injuries.
Choice D reason:
Recapping the needle before disposal is not recommended, as it increases the risk of needlestick injuries. Many healthcare organizations discourage recapping due to the potential for accidental needle sticks. If recapping is required by local policy, it should be done using a safe method.

A. Place the client in a room with positive airflow. B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room. C. When removing personal protective equipment, remove the gown first. D. Provide a mask for the client when they are outside their room. E. Don a gown when entering the client's room.

Correct Answer is ["A","D","E"]

Explanation

A. Place the client in a room with positive air flow: Placing the client in a room with positive air flow helps prevent the spread of infectious agents within the healthcare facility. This is particularly important for clients with airborne infections.

D. Provide a mask for the client when they are outside their room: Providing a mask for the client when they are outside their room helps prevent the spread of infectious agents to others if the client has a contagious respiratory infection.

E. Don a gown when entering the client's room: Wearing a gown upon entering the client's room helps protect the nurse from contact with the client's body fluids and reduces the risk of transmitting pathogens to other clients or healthcare workers.

B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room: Hand sanitizer is not a substitute for proper handwashing with soap and water. Hand sanitizer may be used in addition to handwashing, but it is not used with such a specific quantity.

C. When removing personal protective equipment, remove gloves first: When removing personal protective equipment, the correct sequence is to remove gloves, perform hand hygiene, and then remove other items such as gown, mask, and eyewear. This helps prevent contamination of the hands during the process.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the Injection?

Correct Answer is A

Explanation

A nurse is caring for a client on a medical-surgical unit. Which of the following actions are part of the isolation precautions for this client?

Correct Answer is ["A","D","E"]

Explanation

A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy?

A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage?

A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?

A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?

A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?

A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?

A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? (Select all that apply.)