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 ["A","C"]
Explanation
A. The nurse should notify the prescriber about the current dose (7 mL/hr) because the patient is ordered 1600 units of heparin per hour. The current infusion rate needs to be assessed in relation to the aPTT result, especially if the aPTT indicates that the patient may be at risk for bleeding.
B. While having a second IV may be useful for administering fluids or medications in case of a bleeding emergency, there is no immediate indication for IV 0.9 saline in this scenario. The priority is to assess the heparin dosage and aPTT before making additional IV arrangements.
C. It’s important to assess the IV site for signs of infiltration, especially since the patient is on heparin therapy. Infiltration can affect the effectiveness of the medication and cause complications, so this assessment is vital.
D. While it is important to verify lab results, the nurse should primarily focus on addressing the current situation regarding the heparin infusion and the patient’s anticoagulation status rather than confirming lab results with the lab technician at this moment.
E. While protamine sulfate is an antidote to heparin, it is not warranted based solely on the aPTT result of 37 seconds. The normal aPTT range is typically around 30-40 seconds, depending on the laboratory standards, and the aPTT may not indicate that the patient requires reversal of heparin at this time.
Correct Answer is B
Explanation
This is the correct time to start monitoring for hypoglycemia. The insulin would have started working by this time, and the nurse can assess for any signs of low blood sugar, such as sweating, shakiness, or confusion.
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