A nurse is caring for a client in the emergency department (ED).

Exhibits

Select the 4 assessment findings on day 2 that require immediate follow-up.

Heart rate

Oxygen saturation

Edema

Temperature

Urine color

Pedal pulses

Answer and Explanation

Correct Answer : A,C,E,F

A. Heart rate: The increased heart rate (108/min) may indicate a developing complication such as hypovolemia or pain. This requires monitoring as it could signal deteriorating status.

B. Oxygen saturation: The SpO₂ level is stable at 96%, which is within an acceptable range and does not indicate an immediate concern.

C. Edema: The increase in sacral and iliac region edema (2+) from day 1 to day 2 suggests worsening swelling and possible fluid accumulation, which could be affecting blood flow and leading to circulatory issues.

D. Temperature: The temperature remains within a normal range, so it does not require immediate intervention.

E. Urine color: Dark, reddish-brown urine suggests possible bleeding or rhabdomyolysis, both of which require immediate follow-up to prevent further complications and assess kidney function.

F. Pedal pulses: The change to 1+ pedal pulses bilaterally and the delayed capillary refill time (6 seconds) indicate reduced perfusion to the lower extremities, which may suggest compromised circulation or increased edema affecting blood flow.

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Correct Answer is A

Explanation

A. Older adults often present with atypical symptoms of UTI, such as confusion or altered mental status, rather than the classic symptoms seen in younger clients.

B. Incontinence can occur in older adults but is not specific to UTI and may result from other conditions.

C. Low back pain is a common symptom of UTI but is not specifically unique to older adults.

D. Urinary retention can occur in various conditions but is not uniquely associated with UTI in older adults.

A. Maintain the client on fluid restriction B. Educate the client that hematuria is expected following the procedure C. Notify the provider immediately if mucus is present in the urine D. Apply skin barrier to the stoma site E. Monitor hourly urine output

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

Explanation

A. Fluid restriction is generally not indicated; maintaining hydration is important to ensure adequate urine output.

B. Hematuria is expected postoperatively due to surgical manipulation and should be explained to the client.

C. Mucus in the urine is common with an ileal conduit since the conduit is created using a portion of the intestine, which naturally produces mucus.

D. Applying a skin barrier protects the skin around the stoma site from irritation and breakdown.

E. Monitoring hourly urine output helps assess kidney function and the patency of the conduit.

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A nurse is caring for a client in the emergency department (ED). Exhibits Select the 4 assessment findings on day 2 that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Á nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?

Correct Answer is A

Explanation

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

Explanation

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A nurse is caring for a client in the emergency department (ED).

Exhibits

Select the 4 assessment findings on day 2 that require immediate follow-up.