A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?

Rationale:

A. "You should use an incentive spirometer every 8 hours." Using an incentive spirometer is important for preventing respiratory complications, but the recommendation should be to use it every 1-2 hours while awake, not just every 8 hours.

B. "Clean the incision daily with hydrogen peroxide." Hydrogen peroxide is too harsh for wound care and can delay healing by damaging new tissue. The incision should be cleaned with mild soap and water or as directed by the healthcare provider.

C. "You can cross your legs at the ankles when sitting down." After a hip replacement, clients should avoid crossing their legs, especially at the knees, to prevent dislocation of the new hip joint.

D. "Install a raised toilet seat in your bathroom." After hip replacement surgery, the client should avoid bending the hip beyond 90 degrees to reduce the risk of dislocation. Installing a raised toilet seat helps the client maintain proper positioning and avoid hip flexion beyond the recommended limit.

Rationale for Correct Choices:

• Antibiotic therapy: The client’s symptoms (flank pain, painful urination, reddish-brown urine), elevated white blood cell count (15,000/mm³), positive nitrites, leukocyte esterase, and blood in the urine suggest a urinary tract infection (UTI) or pyelonephritis. Antibiotics are needed to treat this infection.
• Urinary tract infection: The urinalysis findings of turbid, dark red urine with blood, positive nitrites, and leukocyte esterase, along with symptoms like painful urination, flank pain, and fever, strongly point to a UTI, possibly involving the kidneys.

Rationale for Incorrect Choices:

• Lithotripsy: Lithotripsy is used for kidney stones, but the client’s symptoms don’t suggest kidney stones, as there is no sharp, colicky pain. The symptoms are more aligned with a UTI.
• Indwelling urinary catheter: An indwelling catheter is not needed for this UTI unless there’s urinary retention. The client's main issue is a UTI, and there is no mention of retention or obstruction requiring a catheter.
• Kidney failure: Although BUN and creatinine are elevated, the primary issue is a UTI, not kidney failure. Kidney failure would be characterized by more severe, prolonged renal dysfunction.
• Pneumonia: The symptoms do not suggest pneumonia. The primary symptoms of pneumonia include cough and difficulty breathing, which are not present here. Crackles are more likely due to fluid overload.