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 A
Explanation
Choice A rationale
Terazosin is an alpha-1 adrenergic blocker used primarily to treat hypertension by relaxing blood vessels and improving blood flow.
Choice B rationale
Terazosin is not indicated for heart failure treatment as it does not have direct effects on improving cardiac function or reducing fluid overload.
Choice C rationale
Male pattern baldness is typically treated with medications like minoxidil or finasteride, not terazosin, which targets alpha-1 receptors.
Choice D rationale
Benign prostatic hypertrophy is also treated with terazosin as it relaxes the smooth muscle in the prostate and bladder neck, improving urine flow.
Choice E rationale
Erectile dysfunction is managed with medications like sildenafil or tadalafil, which work by enhancing blood flow, not through alpha-1 adrenergic blockade.
Correct Answer is D
Explanation
Choice A rationale
Brown-colored urine is a common side effect of nitrofurantoin and does not typically indicate a serious issue. It results from the excretion of the drug and its metabolites through the urine, which can change its color.
Choice B rationale
Nitrofurantoin is an antibiotic used to treat urinary tract infections. It does not provide relief for peripheral nerve pain, which is typically treated with medications such as gabapentin or pregabalin that target nerve function.
Choice C rationale
Nitrofurantoin tablets or capsules should not be crushed as this can affect the release mechanism of the medication. Crushing the medication may lead to rapid release and absorption, potentially causing gastrointestinal irritation.
Choice D rationale
Nitrofurantoin can cause pulmonary reactions, including cough, shortness of breath, and chest pain. These symptoms may indicate serious adverse effects such as pulmonary fibrosis or hypersensitivity pneumonitis, necessitating immediate medical attention.
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