A nurse is caring for an older adult client with a history of recurrent urinary tract infections (UTIs) in a long-term care facility. The client is nonverbal and unable to communicate discomfort or changes in urinary habits. During a routine assessment, the nurse notes increased confusion, fever, and foul-smelling urine in the client. What should be the nurse's immediate action?
Perform a bladder scan to check for urinary retention
Start the client on an increased fluid intake regimen
Notify the healthcare provider immediately to order a urine culture and initiate antibiotic treatment
Administer acetaminophen to reduce the fever
The Correct Answer is C
A. Perform a bladder scan to check for urinary retention: While urinary retention may be a concern, the client's symptoms (confusion, fever, foul-smelling urine) indicate a possible UTI, which should be addressed first.
B. Start the client on an increased fluid intake regimen: While fluid intake is important, the client needs immediate medical attention to diagnose and treat a possible infection.
C. Notify the healthcare provider immediately to order a urine culture and initiate antibiotic treatment: Correct. The client's symptoms suggest a urinary tract infection, which requires prompt diagnosis and treatment with antibiotics.
D. Administer acetaminophen to reduce the fever: While fever management is important, it does not address the underlying cause of the symptoms, which is likely a UTI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fever and chills: Fever and chills are signs of infection and do not contraindicate the use of phenazopyridine, which is used for pain relief in UTI.
B. Burning and pain with urination: These are symptoms of a UTI, and phenazopyridine is used to treat the associated discomfort.
C. Bright orange urine: This is a common side effect of phenazopyridine and does not contraindicate its use.
D. History of renal impairment: Phenazopyridine is contraindicated in patients with renal impairment because it can accumulate in the body, leading to toxicity.
Correct Answer is ["50"]
Explanation
Step 1: Calculate the total volume to be infused.
Volume = Rate × Time
Volume = 150 mL/hr × 12 hr = 1800 mL
Step 2: Calculate the total time of infusion in minutes.
Time = 12 hours × 60 minutes/hour = 720 minutes
Step 3: Calculate the drip rate.
Drip rate (gtt/min) = Total volume (mL) / Time (min) × Drop factor (gtt/mL)
Drip rate = 1800 mL / 720 min × 20 gtt/mL
Drip rate = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
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