Nokea
A client presents with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.)
- A. Palpate the kidneys and bladder.
- B. Assess the medical history and current medical problems.
- C. Perform a bladder scan to assess post-void residual.
- D. Inquire about recent travel to foreign countries.
Correct Answer: B
Rationale: When assessing a client with a fungal UTI, the nurse should prioritize gathering information related to the medical history and current medical problems. Clients who are severely immunocompromised or have conditions like diabetes mellitus are more susceptible to fungal UTIs. Assessing the medical history helps identify risk factors and potential causes of the infection. While physical examinations like palpating the kidneys and bladder and performing a bladder scan may be necessary, they should follow the initial assessment of medical history. Inquiring about recent travel to foreign countries is less relevant in the context of a fungal UTI, as the focus should be on immediate medical factors predisposing the client to the infection.
You may also like to solve these questions
A healthcare professional has a prescription to collect a 24-hour urine specimen from a client. Which of the following measures should the healthcare professional take during this procedure?
- A. Keeping the specimen chilled
- B. Saving the first urine specimen collected at the start time
- C. Discarding the last voided specimen at the end of the collection time
- D. Asking the client to void, discarding the specimen, and noting the start time
Correct Answer: D
Rationale: The correct answer is asking the client to void, discarding the specimen, and noting the start time. During a 24-hour urine collection, the first voided urine is discarded to ensure the test starts with an empty bladder. The specimen should be kept chilled, not at room temperature, to prevent bacterial growth. The last voided specimen is not discarded because it contributes to the total volume collected, so choice C is incorrect. Discarding the specimen and noting the start time is essential for accurate results in a timed quantitative determination like a 24-hour urine collection.
A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client?
- A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed
- B. Discard the residual volume properly and record it as output on the client's fluid balance record
- C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger
- D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger
Correct Answer: A
Rationale: After checking the residual feeding contents, the nurse should pour the residual volume back into the stomach by removing the syringe bulb or plunger and then pouring the gastric contents, using the syringe, into the nasogastric tube. This helps ensure that the residual volume is reintroduced into the client's gastrointestinal tract. Option B is incorrect because discarding the residual volume without reinstilling it into the stomach can lead to inaccurate medication administration and potential electrolyte imbalances. Option C is incorrect as diluting the residual volume with water and injecting it under pressure can cause aspiration or discomfort for the client. Option D is incorrect because mixing the residual volume with the formula can alter the prescribed dosage and consistency, potentially affecting the client's nutritional intake and causing complications.
The nurse is caring for a patient who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/hour. The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which action will the nurse take?
- A. Decrease the IV fluid rate and notify the provider.
- B. Increase the IV fluid rate and notify the provider.
- C. Request an order for a colloidal IV solution.
- D. Request an order for a hypertonic IV solution.
Correct Answer: A
Rationale: The patient is showing signs of fluid volume excess, indicated by crackles in both lungs, increased heart rate, and elevated blood pressure. To address this, the nurse should decrease the IV fluid rate and notify the provider. Increasing the IV fluid rate would worsen fluid overload. Requesting colloidal or hypertonic IV solutions would exacerbate the issue by pulling more fluids into the intravascular space, leading to further volume overload.
A client has pyelonephritis and expresses embarrassment about discussing symptoms. How should the nurse respond?
- A. Assure the client that their symptoms will be kept confidential.
- B. Acknowledge the client's discomfort and avoid discussing elimination topics.
- C. Encourage the use of familiar language and assure the client they can take their time.
- D. Offer the client a nurse of the same gender to provide care.
Correct Answer: C
Rationale: When a client expresses embarrassment or discomfort in discussing symptoms related to sensitive topics like elimination and the genitourinary area, the nurse should respond by encouraging the client to use words they are comfortable with. This helps the client feel more at ease and opens up communication. Offering a nurse of the same gender may not address the client's discomfort with discussing symptoms. Assuring confidentiality is important, but it should not be promised in a way that may not be fulfilled. Avoiding the topic of elimination entirely does not address the client's feelings or promote effective communication.
A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should tell the client that:
- A. The test may be painful
- B. The test takes 2 to 3 hours
- C. Food and fluids are not allowed for 4 hours after the test
- D. Dye is injected and may cause a warm flushing sensation
Correct Answer: D
Rationale: The correct answer is D. A contrast-aided CT scan involves the injection of dye to enhance the images obtained. The dye may cause a warm flushing sensation when injected, which is a common side effect. Choices A, B, and C are incorrect. CT with contrast is generally not a painful procedure, the duration of the test does not usually take 2 to 3 hours, and restrictions on food and fluids are typically before the test, not afterward.