A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

Temperature 37.3° C (99.1° F)

WBC Count 9,000/mm3

Changed mental status

Diminished reflexes

Answer and Explanation

The Correct Answer is C

A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.

A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.

B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.

D: Diminished reflexes are not typically associated with a bladder infection.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Applying traction weight to the external fixator is not recommended, as it can cause excessive stress on the pins and wires, leading to complications such as infection, loosening, or breakage 1.Traction is usually applied to skeletal pins that are inserted into the bone without an external frame 2.

Choice B rationale: Monitoring the neurovascular status of the affected limb is important, but every 8 hours is not frequent enough.The nurse should perform neurovascular checks every 2 to 4 hours for the first 24 hours, then every 4 to 8 hours, according to the facility policy 3. This is to assess for signs of nerve damage, compartment syndrome, or impaired circulation, which can result from the injury or the device.

Choice C rationale: Administering pain medication 30 min prior to pin care is a correct intervention, as it can help reduce the discomfort and anxiety associated with the procedure. Pin care involves cleaning the pin sites with an antiseptic solution and applying sterile dressings to prevent infection and promote healing. The frequency and technique of pin care may vary depending on the type of device, the condition of the wound, and the facility protocol.

Choice D rationale: Adjusting the clamps on the device’s frame daily is not a nursing intervention, as it can alter the alignment and stability of the fracture. The clamps should be tightened only by the orthopedic surgeon or a trained technician, and only when necessary. The nurse should inspect the device for any loose or broken parts and report any problems to the surgeon.

So, the correct answer is Choice C, after analysing all choices.

A. Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally. B. Remove the needle and release the tissue. C. Aspirate by pulling back on the plunger and inject the medication.

Correct Answer is A,C,B

Explanation

Here’s the correct sequence for administering ceftriaxone using the Z-track technique: 1. Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally. 2. Aspirate by pulling back on the plunger and inject the medication. 3. Remove the needle and release the tissue. This method helps to prevent the medication from leaking into the subcutaneous tissue, reducing irritation and discomfort.

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A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is A,C,B

Explanation

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