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An emergency department nurse assesses a client with kidney trauma and notes that the client's abdomen is tender and distended, and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation?
- A. Assessing vital signs every 15 minutes
- B. Inserting an indwelling urinary catheter
- C. Administering intravenous fluids at 125 mL/hr
- D. Typing and crossmatching for blood products
Correct Answer: B
Rationale: In a client with kidney trauma and blood visible at the urinary meatus, inserting a urinary catheter via the urethra should be avoided until further diagnostic studies are completed to prevent potential urethral tears. The nurse should consult the provider about the need for a catheter; if necessary, a suprapubic catheter can be used instead. Assessing vital signs every 15 minutes is important for continuous monitoring of the client's condition. Administering intravenous fluids at 125 mL/hr is crucial to maintain hydration and support kidney function. Typing and crossmatching for blood products is necessary in case the client requires blood transfusion due to potential blood loss from the trauma.
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A nurse reviews a female client's laboratory results. Which result from the client's urinalysis should the nurse recognize as abnormal?
- A. pH 5.6
- B. Ketone bodies present
- C. Specific gravity of 1.020
- D. Clear and yellow color
Correct Answer: B
Rationale: The correct answer is B: Ketone bodies present. Ketone bodies in urine indicate abnormal metabolism, specifically the incomplete breakdown of fatty acids. Normally, there should be no ketones present in urine. Ketone bodies are produced when the body uses fat sources instead of glucose for cellular energy. A pH range between 4.6 and 8, a specific gravity between 1.005 and 1.030, and clear yellow color in urine are considered normal findings for a female client's urinalysis. Therefore, options A, C, and D are within normal ranges and not indicative of abnormal results in the urinalysis.
The nurse is preparing to administer the first dose of an antibiotic to a patient admitted for a urinary tract infection. Which action is most important prior to administering the antibiotic?
- A. Administering a small test dose to determine if hypersensitivity exists
- B. Having epinephrine available in case of a severe hypersensitivity reaction
- C. Monitoring baseline vital signs, including temperature and blood pressure
- D. Obtaining a specimen for culture and sensitivity
Correct Answer: D
Rationale: The most crucial action before administering an antibiotic for a urinary tract infection is to obtain a specimen for culture and sensitivity. This ensures the accurate identification of the causative organism and helps determine the most effective antibiotic therapy. Administering a test dose to detect hypersensitivity is usually reserved for cases with a strong suspicion of allergy to a needed antibiotic. Keeping epinephrine available is important when there is a significant risk of a severe allergic reaction. Monitoring baseline vital signs is essential during antibiotic therapy but is not the top priority before administering the first dose.
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.
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 client tells the nurse that he has been experiencing frequent heartburn and has been 'living on antacids.' For which acid-base disturbance does the nurse recognize a risk?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: B
Rationale: The correct answer is B: Metabolic alkalosis. In this scenario, the client's frequent use of antacids containing alkaline components can lead to an excess of bicarbonate in the body, causing metabolic alkalosis. Oral antacids work by neutralizing stomach acid, potentially leading to an alkaline shift in the body's pH balance. Choices A, C, and D are incorrect. Metabolic acidosis is not typically associated with antacid use. Respiratory acidosis and respiratory alkalosis are related to respiratory system dysfunction rather than antacid ingestion.