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 B
Explanation
A. Vomiting: While vomiting can occur during anaphylaxis, it is not the most immediately life-threatening symptom.
B. Stridor: Stridor indicates upper airway obstruction, which is a critical and life-threatening sign of anaphylaxis. This finding requires immediate intervention, such as administering epinephrine and ensuring airway patency.
C. Hypertension: Hypertension is not typically associated with anaphylaxis; instead, hypotension is more common due to vascular collapse.
D. Urticaria: Urticaria (hives) can occur in anaphylaxis, but it is not as urgent as stridor, which indicates a compromised airway.
Correct Answer is A
Explanation
A. Tachycardia: Theophylline can cause tachycardia as a side effect due to its stimulant properties.
B. Constipation: While gastrointestinal effects can occur, constipation is not a common or significant adverse effect of theophylline.
C. Oliguria: Theophylline is more likely to cause diuresis rather than oliguria.
D. Drowsiness: Theophylline typically causes stimulation rather than sedation, leading to increased alertness rather than drowsiness.