A 72-year-old client is admitted to the medical-surgical unit with a diagnosis of acute pyelonephritis. The client complains of costovertebral tenderness. What it the most appropriate nursing intervention?
Notify the physician since this is a sign of deterioration.
Offer the client back massage to reduce the pain.
Place the client in prone position to limit vesicoureteral reflux.
Offer the client an analgesic if prescribed.
The Correct Answer is D
A. While costovertebral tenderness is significant and indicates kidney involvement, it is a common symptom of acute pyelonephritis and not necessarily a sign of deterioration. Immediate notification may not be warranted unless other concerning symptoms are present.
B. Although back massage may seem comforting, it is not indicated in this scenario. The kidneys are inflamed, and massage could exacerbate pain or discomfort. It does not address the underlying condition or the pain effectively.
C. The prone position is not typically recommended for clients with pyelonephritis. Instead, the client may be more comfortable in a position that does not put pressure on the kidneys, such as sitting up or lying on their back or side. This intervention does not directly address the pain or comfort of the client.
D. Offering an analgesic is the most appropriate action. Pain management is crucial for the comfort of the client, and an analgesic can help alleviate the discomfort associated with costovertebral tenderness. If the physician has prescribed an analgesic, administering it would be in line with promoting comfort and addressing the client’s needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This is a normal platelet count and is not directly related to DVT.
B. This is a normal PT result and does not indicate a clotting disorder that would predispose the client to DVT.
C. This is a normal aPTT result and does not indicate a clotting disorder that would predispose the client to DVT.
D. D-dimer is a marker of blood clot breakdown. An elevated D-dimer level suggests the presence of a blood clot, making it the most concerning laboratory result in this case.
Correct Answer is ["12.5"]
Explanation
1 kilogram equals 2.2 pounds.
110 lbs, which is equivalent to 50 kg (110 lbs / 2.2).
The prescribed dose is 2 mg/kg/day, so the total daily dose is 100 mg (2 mg/kg * 50 kg). This total daily dose is divided into four doses, which means each dose is 25 mg (100 mg / 4).
The medication is supplied as 10 mg/5 mL, so for a 25 mg dose, the nurse will administer 12.5 mL (25 mg * (5 mL / 10 mg)). Therefore, the nurse will administer 12.5 mL per dose.
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