A client is admitted to the emergency room with renal colic due to renal lithiasis (stones). What is the nurse's highest priority in managing care for this client?
Prepare the client for lithotripsy to break up the stones.
Order a renal ultrasound to assess for the presence and location of the stones.
Administer pain medication as prescribed.
Initiate intravenous (IV) fluid therapy.
The Correct Answer is C
Choice A rationale
Preparing the client for lithotripsy is important for treatment but is not the immediate highest priority in an emergency setting. Immediate pain management takes precedence.
Choice B rationale
Ordering a renal ultrasound is necessary for assessing the stones but comes after stabilizing the client's acute symptoms, including managing pain.
Choice C rationale
Administering pain medication as prescribed is the highest priority because renal colic causes severe pain. Immediate pain relief is crucial for the client's comfort and to facilitate further diagnostic and therapeutic interventions.
Choice D rationale
Initiating IV fluid therapy is important for hydration and possibly aiding stone passage but follows after addressing the acute pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Taking nitroglycerin when experiencing chest pain is correct as it helps to relieve the pain by dilating blood vessels and increasing blood flow to the heart.
Choice B rationale
Calling 911 if chest pain does not improve after taking nitroglycerin is correct and necessary to seek immediate medical assistance.
Choice C rationale
Storing nitroglycerin tablets in a dark, cool place is correct to maintain their potency, as light and heat can degrade the medication.
Choice D rationale
Taking up to three doses of nitroglycerin five minutes apart is correct; however, if the pain persists after one dose, the patient should call 911 immediately rather than waiting for all three doses to be taken.
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Infusing 10 percent dextrose and water prevents hypoglycemia if TPN is temporarily unavailable. This is a crucial step in maintaining the patient's blood sugar levels.
Choice B rationale
Shaking the TPN bag with fat emulsion can cause the emulsion to break, leading to potential complications. Fat emulsions should be mixed gently.
Choice C rationale
Maintaining the TPN infusion rate when behind schedule is incorrect as it can lead to rapid infusion and complications such as hyperglycemia and fluid overload.
Choice D rationale
Keeping the TPN refrigerated when not in use helps to maintain its stability and prevent bacterial contamination. Proper storage is essential for patient safety. .
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