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A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. WBC count 9,000/mm³ (5,000 to 10,000/mm³)
- B. Temperature 37.3° C (99.1° F)
- C. Changed mental status
- D. Diminished reflexes
Correct Answer: C
Rationale: Bladder infections (UTIs) in older adults often present atypically, with mental status changes like confusion being a hallmark due to systemic inflammation or bacteremia. WBC count of 9,000/mm³ is normal, not clearly indicating infection unless trending up; leukocytosis (e.g., >10,000) is more specific. Temperature of 37.3°C is a low-grade fever, possible but not definitive for UTI without other signs. Diminished reflexes relate to neurologic or age-related issues, not infection. Altered mental status, however, is a red flag older adults may lack classic UTI symptoms (e.g., dysuria), and confusion signals potential sepsis or delirium, per geriatric assessment guidelines. This finding warrants urgent reporting for urinalysis and treatment, preventing progression, making it the strongest indicator of a bladder infection.
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A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
- A. Allow the site to dry.
- B. Pierce the puncture site quickly.
- C. Squeeze the site gently to obtain a blood droplet.
- D. Cleanse the site with an antiseptic swab.
- E. Apply blood to the test strip.
Correct Answer: D,A,B,C,E
Rationale: The order is: Cleanse with antiseptic (D), allow to dry (A), pierce (B), squeeze for blood (C), and apply to strip (E) for an accurate, sterile sample.
A home health nurse is reinforcing teaching with an older adult client about safety precautions to take in the home. Which of the following instructions should the nurse include?
- A. Place white tape on the edges of stairs.
- B. Place area rugs on wooden floors.
- C. Run wires and cords under carpeting.
- D. Have the furnace inspected every 2 years.
Correct Answer: A
Rationale: White tape on stair edges improves visibility, reducing fall risk in older adults. Rugs and hidden cords are trip hazards, and furnace checks should be annual, not biennial.
A nurse is reinforcing teaching with a client who is starting to take metformin extended release. Which of the following instructions should the nurse include in the instructions?
- A. Monitor blood glucose while taking this medication
- B. Expect muscle pain while taking this medication.
- C. Take the medication with breakfast.
- D. Chew the medication before swallowing.
- E. Take it on an empty stomach.
- F. Expect weight gain as a side effect.
- G. Avoid all carbohydrates while on this.
Correct Answer: A
Rationale: Metformin requires glucose monitoring to assess efficacy and prevent hypoglycemia; muscle pain isn't typical, it's taken with food to reduce GI upset, and it's not chewed.
A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications?
- A. Palpate the client's brachial pulses and compare bilaterally.
- B. Check for jugular vein distention while the client is supine.
- C. Check the client's blood pressure while the client lies supine, sits, and stands.
- D. Palpate the client's pedal pulses and compare bilaterally.
- E. Monitor respiratory rate.
- F. Check for chest pain.
- G. Assess skin temperature.
Correct Answer: D
Rationale: Pedal pulses assess for femoral artery complications like hematoma or occlusion.
A nurse is reinforcing teaching with a female client who has a history of urinary tract infections. Which of the following instructions should the nurse include?
- A. Increase milk consumption to make the urine more alkaline.
- B. Urinate before and after sexual intercourse.
- C. Use a vaginal douche once a week.
- D. Empty the bladder at least every 6 hr.
Correct Answer: B
Rationale: Urinating before and after sexual intercourse flushes bacteria from the urethra, a primary UTI prevention strategy, especially in women due to their shorter urethra. Milk consumption may alkalinize urine, but this doesn't prevent infection cranberry juice is more evidence-based, reducing bacterial adhesion. Vaginal douching disrupts normal flora, increasing UTI risk by promoting pathogen growth, contrary to hygiene goals. Emptying the bladder every 6 hours helps, but more frequent voiding (e.g., every 2-3 hours) is ideal; post-coital urination targets the key risk moment. This instruction empowers the client to reduce recurrence, aligns with urologic recommendations, and addresses a common trigger, making it the most effective teaching point.