A nurse is collecting data from an older adult client.Which of the following findings should the nurse identify as indicating the client has a bladder infection?
Changed mental status.
WBC Count 9,000/mm³ (5,000 to 10,000/mm³).
Diminished reflexes.
Temperature 37.3°C (99.1°F).
The Correct Answer is A
Choice A rationale
A changed mental status is a common sign of a urinary tract infection, especially in older adults, due to the effects of the infection on the central nervous system.
Choice B rationale
WBC count 9,000/mm³ is within the normal range of 5,000 to 10,000/mm³ and does not indicate an infection on its own.
Choice C rationale
Diminished reflexes are not typically associated with bladder infections and are not a reliable indicator.
Choice D rationale
A temperature of 37.3°C (99.1°F) is within the normal range and does not necessarily indicate a bladder infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Platelets 60,000/mm³ is significantly below the normal range of 150,000 to 400,000/mm³, which can indicate a risk of bleeding and is a concern for a procedure like a liver biopsy.
Choice B rationale
Ammonia levels of 55 mcg/dL are within the normal range of 10 to 80 mcg/dL, so this value does not need to be reported.
Choice C rationale
Bilirubin 1.0 mg/dL is at the upper limit of the normal range of 0.3 to 1.0 mg/dL, but it does not necessarily indicate a significant risk for a liver biopsy.
Choice D rationale
Aspartate aminotransferase 34 units/L is at the upper limit of the normal range of 0 to 34 units/L, but it does not indicate a contraindication for the biopsy.
Correct Answer is C
Explanation
Choice A rationale
Rotating the jejunostomy tube daily is not necessary and may cause unnecessary discomfort or complications.
Choice B rationale
Administering the feeding solution at a cold temperature can cause abdominal cramping and discomfort. It should be given at room temperature.
Choice C rationale
Elevating the head of the client's bed for 1 hour after feeding helps prevent aspiration, a serious complication of enteral feedings.
Choice D rationale
Flushing the tube with 90 mL of sterile water is excessive; the standard practice is to use 30-60 mL to clear the tube before and after feedings. .
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