A nurse on a rehabilitative unit is caring for a 65-year-old female client who is postoperative following knee arthroplasty.
The nurse is evaluating the client. Select the 2 findings that require immediate follow-up.
Oral fluid intake
Urinalysis
Report of sensation upon urination
Color of urine
Correct Answer : B,C
Choice A rationale: While oral fluid intake is important for hydration and general health, it is not an immediate priority unless there is evidence of dehydration, which is not present here. The client’s main issues are urinary symptoms and infection.
Choice B rationale: Urinalysis results showing cloudy appearance, foul odor, and elevated pH indicate a urinary tract infection (UTI), which requires immediate follow-up due to the risk of sepsis and worsening infection if untreated. Normal urine should be clear, aromatic, and have a pH of 4.6–8.0.
Choice C rationale: The client’s report of burning sensation upon urination is a classic symptom of a UTI. Dysuria, urgency, and frequency are concerning signs of infection that require prompt medical attention to prevent complications such as pyelonephritis or bacteremia.
Choice D rationale: While the amber yellow color of urine is within normal range, the associated symptoms and laboratory findings are more concerning. The color alone does not indicate an immediate issue compared to the urinalysis and reported urinary discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Antibiotics like ciprofloxacin should be taken for the full prescribed duration to ensure complete eradication of the infection and prevent antibiotic resistance.
Choice B rationale
Ciprofloxacin increases photosensitivity by forming free radicals in the skin when exposed to ultraviolet light, raising the risk of sunburn. Normal skin phototype varies by individual.
Choice C rationale
Ciprofloxacin's absorption can be inhibited by calcium-containing products like milk. It should be taken with water to ensure proper absorption and therapeutic efficacy.
Choice D rationale
Ciprofloxacin can interact with oral contraceptives, but the effectiveness of birth control pills is not significantly decreased. Additional contraceptive methods are advised for safety. .
Correct Answer is A
Explanation
Choice A rationale
Infiltration of the peripheral IV can cause tissue damage and decreased medication efficacy. Immediate intervention is required to prevent complications.
Choice B rationale
Increased blood pressure can be a common effect of dopamine infusion. Monitoring and dose adjustment may be needed, but it is not an immediate threat.
Choice C rationale
Occasional PVCs can occur with dopamine infusion. While monitoring is necessary, they are not immediately life-threatening and may not require urgent intervention.
Choice D rationale
A heart rate of 105/min is a common side effect of dopamine and does not usually necessitate immediate intervention unless accompanied by other symptoms.
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