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 A
Explanation
Choice A rationale
Dysuria, or painful urination, is a common symptom of acute cystitis (bladder infection). Clients with acute cystitis often report burning sensations during urination and frequent urges to urinate.
Choice B rationale
Nasal congestion is not a symptom associated with acute cystitis. It is more commonly related to respiratory conditions like colds or allergies.
Choice C rationale
Joint pain is not related to acute cystitis. Joint pain can be associated with various musculoskeletal or autoimmune conditions, but not typically with a bladder infection.
Choice D rationale
Shortness of breath is not a symptom of acute cystitis. This symptom is more relevant to respiratory or cardiovascular conditions, not bladder infections.
Correct Answer is D
Explanation
Choice A rationale
Visible signs of bone healing on an X-ray would not be expected after Buck's traction. Healing takes longer to become visible on an X-ray.
Choice B rationale
Increased swelling and redness would indicate complications such as infection or thrombophlebitis, not the effectiveness of traction.
Choice C rationale
Improved range of motion would not typically be expected while Buck's traction is in place. The primary purpose is to reduce pain and immobilize the fracture.
Choice D rationale
Decrease in hip pain is a direct indicator of the effectiveness of Buck's traction in alleviating symptoms and preventing further injury to the fractured femur.
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