A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?
Urinary retention
Urinary tract infection
Urinary incontinence
Urinary frequency
The Correct Answer is B
A. Urinary retention typically presents with difficulty urinating, rather than changes in urine color or odor.
B. Dark amber, cloudy urine with an unpleasant odor is indicative of a urinary tract infection (UTI). The cloudiness suggests the presence of bacteria or pus, while the dark color and odor are common signs of infection.
C. Urinary incontinence is characterized by the involuntary loss of urine, not changes in the characteristics of urine.
D. Urinary frequency refers to the need to urinate more often, which does not directly relate to the appearance or odor of the urine.
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Correct Answer is D
Explanation
A. Filling out an occurrence form is necessary for documentation and accountability but is not the immediate priority after a medication error.
B. Administering the medication to the correct client should be done, but first, the nurse must ensure the safety and well-being of the client who received the wrong medication.
C. Notifying the client's provider is essential, but the nurse should first assess the client's condition to determine if any immediate actions are necessary.
D. Checking the client's vital signs is the first action the nurse should take to assess the client's current condition and any potential adverse effects from receiving the incorrect medication.
Correct Answer is B
Explanation
A. Observing the client is inappropriate as they are demonstrating signs of choking and require immediate intervention.
B. Performing the Heimlich maneuver is appropriate as the guest is unable to talk, which indicates a potential airway obstruction that needs to be relieved promptly.
C. Slapping the client on the back may not be effective and could worsen the obstruction, especially since they are grasping their throat.
D. Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate in this situation, as the priority is to clear the obstruction, not to provide rescue breaths.