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","C","D"]
Explanation
A. Perform passive range of motion exercises. Passive range of motion exercises help maintain circulation and reduce venous stasis, which is crucial for preventing pulmonary embolism in clients who are immobile.
B. Place pillows under the client's knees when in bed. Placing pillows under the knees can actually promote venous stasis and increase the risk of a pulmonary embolism. It is better to keep the legs flat to encourage circulation.
C. Assess legs for redness. Regular assessment of the legs for redness, swelling, or warmth helps in the early detection of deep vein thrombosis (DVT), which can lead to pulmonary embolism if not addressed.
D. Apply elastic compression stockings. Elastic compression stockings promote venous return from the legs to the heart and help prevent DVT, thereby reducing the risk of pulmonary embolism.
E. Massage the calves every shift. Massaging the calves can dislodge a thrombus and potentially lead to a pulmonary embolism. Instead, interventions should focus on preventing thrombus formation.
Correct Answer is C
Explanation
A. "Use the peak expiratory flow meter once per week." The peak expiratory flow meter is usually recommended for daily use in asthma management to monitor lung function and detect any changes early.
B. "Take cromolyn sodium at the first sign of breathing difficulty." Cromolyn sodium is a mast cell stabilizer and is used as a preventative medication rather than for quick relief of symptoms, so it should be taken regularly as prescribed, not only when symptoms arise.
C. "Avoid triggers that cause an attack." Avoiding known asthma triggers is an important part of asthma management to prevent attacks and exacerbations.
D. "You should stop playing basketball, but you can swim instead." Exercise should not necessarily be avoided; instead, it should be managed appropriately with pre-treatment if needed. Avoiding all sports activities is not generally recommended.