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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Administering packed RBCs is important but is not the highest priority. Stabilizing the client’s hemodynamic status is critical first.

Choice B rationale

Elevating the client's feet can help with blood circulation but does not address the immediate need to stabilize blood pressure and fluid volume.

Choice C rationale

Initiating a dopamine IV infusion can help with hypotension, but it is not the first action. Stabilizing the client with fluids is a higher priority.

Choice D rationale

Increasing the client's IV fluid rate is the highest priority to address hypotension and ensure adequate blood volume before administering blood products or other medications. .

A. To provide essential nutrients while allowing the bowel to rest and heal. B. To reduce inflammation and control symptoms of IBD. C. To stimulate the bowel and promote regular bowel movements. D. To prevent malnutrition and promote weight gain.

Correct Answer is A

Explanation

Choice A rationale

Total parenteral nutrition (TPN) provides essential nutrients intravenously, allowing the bowel to rest and heal, which is important in the management of inflammatory bowel disease (IBD).

Choice B rationale

While reducing inflammation and controlling symptoms are important goals in IBD management, TPN is primarily used to provide nutrition and allow the bowel to rest.

Choice C rationale

Stimulating the bowel is not the purpose of TPN. TPN is used to give the digestive tract a break while ensuring the patient receives necessary nutrients.

Choice D rationale

Preventing malnutrition and promoting weight gain are secondary benefits of TPN, but the primary rationale is to provide nutrients while allowing the bowel to rest and heal.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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