Today’s NCLEX-RN® question of the day focuses on a nurse’s best response about a 91-year-old client who arrives at the emergency department for altered mental status. Can you figure it out?
A 91-year-old client arrives at the emergency department for altered mental status. The client’s blood pressure is 82/48 mmHg and heart rate is 118/min. A urine sample is obtained and shows a white blood cell count of >60 WBC/hpf. Which intervention should the nurse perform first?
A. Administer the prescribed antibiotic
B. Prepare the client for the operating room
C. Contact the on-call urologistD. Insert an indwelling catheter
Scroll down for the correct answer!
The correct answer to today’s NCLEX-RN® Question is…
A. Administer the prescribed antibiotic
Rationale: The normal range of white blood cells in the urine is 2-5 WBCs/hpf or less so this result indicates the client has a UTI. This client also has symptoms indicating sepsis, such as hypotension and tachycardia. Therefore, the nurse should administer the ordered antibiotic as soon as possible to treat the infection.
Major Takeaway
The normal range of white blood cells in the urine is 2-5 WBCs/hpf or less. This lab result indicates the client has a urinary tract infection (UTI) and their vital signs indicate possible sepsis, or a systemic infection. Since the client displays hemodynamic instability, such as hypotension and tachycardia, the nurse should administer the prescribed antibiotic first to treat the infection. The additional interventions for clients with UTIs typically include intravenous hydration, client education, and possible surgical intervention or follow-up with a urologist if required.
Incorrect answer explanations
B. Prepare the client for the operating room
Rationale: In certain cases, clients with recurrent UTIs require urological surgery. This is most frequently the case when there are calculi present along the urinary tract, an enlarged prostate, or anatomical abnormalities. However, there is nothing indicating this client requires surgical intervention at this time.
C. Contact the on-call urologist
Rationale: Urology clinicians may be involved in the care of clients with a UTI. Although the on-call urologist may be consulted, this is not the highest priority intervention for the nurse.
D. Insert an indwelling catheter
Rationale: This client may require urinary catheterization if they are retaining urine; however, in this client’s case, another intervention should take priority. In addition, indwelling catheters can introduce additional bacteria to the urinary tract.
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