A nurse is caring for a client on the medical-surgical unit.
The Correct Answer is []
Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.
Actions to take:
- Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
- Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.
Parameters to monitor:
- Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
- Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.
Incorrect diagnoses:
The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased appetite: Not typical in AKI; anorexia is more common.
B. Elevated serum creatinine levels: A hallmark of AKI, indicating reduced kidney filtration capacity.
C. Hyperglycemia: Not a direct indicator of AKI, though may occur in diabetics.
D. Increased urine output: AKI is typically oliguric (low urine output) or anuric in early phases.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Critical to assess: A. Airway patency and signs of inhalation injury
Clients in enclosed-space fires are at high risk for inhalation injury, which can lead to airway edema and obstruction. This is the first priority.
Critical assessment finding: C. Singed nasal hairs and soot around the nares
These are hallmark signs of possible inhalation injury and may indicate airway compromise even before symptoms become severe.
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