A nurse is caring for an older adult client who was admitted with a urinary tract infection.

Findings upon admission:

The nurse is assessing the client 12 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Exhibits
Findings 12 hr later: Unrelated to diagnosis /Indication of potential improvement / Indication of potential worsening of condition

Oxygen saturation 96% at 2 L/min via nasal cannula

Disoriented to person, place, and time

Blood pressure 100/50 mm Hg

Hct 45%

Pink-tinged urine

Butterfly rash

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

A)   An increase in oxygen saturation to 96% at a reduced oxygen flow rate indicates potential improvement in respiratory function, which can be a positive sign of recovery from a UTI.
B)   Disorientation to person, place, and time suggests a potential worsening of the condition, as UTIs can cause confusion, especially in older adults and those with dementia.
C)   A drop in blood pressure to 100/50 mm Hg could indicate potential worsening, as it may suggest dehydration or sepsis, both of which can complicate a UTI.
D)   A decrease in hematocrit (Hct) to 45% is within the normal range and could indicate an improvement if previously elevated due to dehydration.
E)   Pink-tinged urine may indicate the presence of blood, a sign of potential worsening, as it could suggest a more severe infection or other complications.
F)   A butterfly rash is not typically associated with a UTI and may be unrelated to the current diagnosis; in this scenario it is related to the patient’s history of systemic lupus erythematosus.

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Free Nursing Study Resources

Correct Answer is {"xRanges":[413.765625,473.765625],"yRanges":[424.609375,484.609375]}

Explanation

A transverse colon colostomy is typically placed in the upper abdomen, either in the middle or toward the right side of the body. In the above scenario the best location will be B which is located along the path of the transverse colon. Point A would be suitable for an ileostomy while point B will be suitable for a sigmoid colostomy.

A. Change dressings over the entrance and exit wounds. B. Obtain an ECG. C. Administer an opioid pain medication. D. Titrate IV fluids to maintain urine output at 75 mL/hr.

Correct Answer is B

Explanation

A. Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B. Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C. Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D. While maintaining adequate urine output is important, assessing cardiac status takes precedence.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"xRanges":[413.765625,473.765625],"yRanges":[424.609375,484.609375]}

Explanation

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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