The nurse is caring for a client who appears anxious and fearful. The client has recently been seen for a urinary tract infection and reports their urine has turned an orange-red color. What is the best response by the nurse?
"This may mean that your liver is failing and you need immediate medical attention."
"This is an expected finding for someone with a diet high in red meat.”
“This is a symptom that your urinary tract infection is worsening. I will notify the provider.”
“This is an expected finding if you are taking the over the counter medication, Phenazopyridine.”
The Correct Answer is D
A. "This may mean that your liver is failing and you need immediate medical attention." This statement is misleading; orange-red urine is not typically a sign of liver failure, especially in the context of a urinary tract infection.
B. "This is an expected finding for someone with a diet high in red meat." While diet can affect urine color, red meat is not commonly associated with orange-red urine; this is not a relevant response given the client's context.
C. “This is a symptom that your urinary tract infection is worsening. I will notify the provider.” While it is important to monitor urinary tract infections, orange-red urine is more likely related to the use of phenazopyridine rather than a worsening infection.
D. “This is an expected finding if you are taking the over-the-counter medication, Phenazopyridine.” Phenazopyridine is known to cause orange-red discoloration of urine, and this statement provides reassurance to the client regarding their symptoms
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Correct Answer is A
Explanation
A. Daily or weekly weight: Daily or weekly weight measurements are a reliable way to assess fluid retention. A sudden increase in weight can indicate fluid overload.
B. Sodium level: While sodium levels can provide some information about fluid balance, they are not as direct or reliable as weight measurements for assessing fluid retention.
C. Tissue turgor: Tissue turgor can give some insight into hydration status but is subjective and less reliable compared to weight measurements, especially in clients with chronic conditions.
D. Intake and output: While monitoring intake and output is important for assessing fluid balance, it may not accurately reflect fluid retention, as it doesn't account for fluid shifts or loss through other routes.
Correct Answer is D
Explanation
A. Limit caffeine intake. While caffeine can affect some patients, it is not a specific concern with inhaled corticosteroids like beclomethasone.
B. Take the medication with meals. Inhaled corticosteroids like beclomethasone are typically not taken with meals as they are inhaled, not ingested.
C. Check the pulse after medication administration. Monitoring the pulse is not necessary for beclomethasone unless the client experiences specific symptoms related to tachycardia, which is not common with inhaled corticosteroids.
D. Rinse the mouth after administration. Rinsing the mouth after using inhaled corticosteroids helps prevent oral thrush and other oral side effects associated with the medication.