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 B
Explanation
Choice A rationale
Hypokalemia involves low potassium levels and is not treated with sodium polystyrene sulfonate. This drug is used to treat elevated potassium levels.
Choice B rationale
Hyperkalemia indicates high potassium levels in the blood. Sodium polystyrene sulfonate (Kayexalate) works by exchanging sodium ions for potassium ions in the intestines, thereby lowering blood potassium levels.
Choice C rationale
Hyponatremia, or low sodium levels, is not treated with sodium polystyrene sulfonate, which targets potassium removal.
Choice D rationale
Hypocalcemia refers to low calcium levels and is unrelated to the action of sodium polystyrene sulfonate, which addresses potassium imbalance.
Correct Answer is A
Explanation
Choice A rationale
Radiating pain to the left arm is a classic symptom of a myocardial infarction (MI) due to referred pain from the heart.
Choice B rationale
Shortness of breath can also be associated with MI but is not as specific as radiating pain to the left arm.
Choice C rationale
Headache is not a typical symptom of an MI. It is more commonly associated with other conditions.
Choice D rationale
Nausea and vomiting can occur with an MI but are not as specific as radiating pain to the left arm.
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