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","C","D","E"]
Explanation
Choice A rationale: Fluid intake is essential for maintaining hydration and overall health, especially for clients with bipolar disorder. However, it is not the most immediate concern unless specific signs of dehydration or other related issues are noted.
Choice B rationale: Gastrointestinal findings require follow-up because medication changes can cause nausea, vomiting, or other gastrointestinal disturbances. These symptoms can affect the client's nutrition and overall well-being, particularly with new medications in bipolar disorder management.
Choice C rationale: Muscle movement findings such as tremors, stiffness, or involuntary movements should be monitored. These can indicate side effects of psychiatric medications, including extrapyramidal symptoms or tardive dyskinesia, which require immediate medical evaluation.
Choice D rationale: Vital signs are crucial to monitor because abnormal readings can indicate adverse effects of medication. For example, certain medications used in bipolar disorder management can affect heart rate and blood pressure, which need regular assessment.
Choice E rationale: Urine output is important to track because changes in renal function can occur with certain medications. Monitoring for any alterations in urine output helps assess potential nephrotoxicity or other renal issues, which are critical for client health.
Correct Answer is A
Explanation
Choice A rationale
Acyclovir is an antiviral medication that inhibits viral DNA synthesis. It reduces the severity and duration of varicella-zoster virus symptoms by targeting the virus directly.
Choice B rationale
Vancomycin is an antibiotic effective against Gram-positive bacteria. It is not effective against viral infections like varicella-zoster, which requires antiviral treatment.
Choice C rationale
Gentamicin is an aminoglycoside antibiotic used to treat Gram-negative bacterial infections. It is ineffective against varicella-zoster virus, which is a viral infection.
Choice D rationale
Quinine is an antimalarial medication used to treat malaria. It does not have antiviral properties and is not effective against varicella-zoster virus.
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