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 []
Explanation
Condition: Myocardial infarction.
2 actions:
Administer oxygen via nasal cannula 2 L/min,
Request a prescription for aspirin 325 mg.
2 parameters:
Vital signs,
Electrocardiogram (ECG) rhythm.
Rationale for correct condition: A myocardial infarction is indicated by the elevated troponin levels and ST elevation on the ECG. The client’s symptoms of chest pain, elevated heart rate, and low oxygen saturation support this diagnosis. Prompt identification and treatment are crucial to minimize heart damage. The medical history of hypertension and coronary artery disease increases the likelihood. Immediate interventions can significantly improve outcomes.
Rationale for actions: Administer oxygen to improve oxygenation and reduce myocardial workload. Requesting aspirin helps prevent further clot formation. Morphine alleviates pain but may obscure symptoms, making it less urgent. Nitroglycerin relieves chest pain by vasodilation but is secondary. Verapamil is less immediate for acute myocardial infarction management. Vital signs reflect hemodynamic status and response to treatment. ECG rhythm detects ongoing ischemia or arrhythmias. Monitoring WBC count is less relevant acutely. Platelet count is stable; not the focus in immediate management.
Rationale for parameters: Vital signs ensure hemodynamic stability and detect hypotension or shock. ECG rhythm monitors arrhythmias and ongoing ischemia, critical in myocardial infarction. WBC count indicates infection or inflammation, less immediate concern. Platelet count is important for bleeding risks but less immediate. Chronic stable angina presents with predictable, non-severe pain. Ischemic stroke symptoms differ; focus on neurological deficits. Cardiogenic shock would present with more severe hypotension and signs of organ failure.
Correct Answer is D
Explanation
Choice A rationale
A complete blood count (CBC) can provide general information about the body's response to an MI, such as white blood cell count, but it is not definitive for diagnosing an MI.
Choice B rationale
A lipid profile measures cholesterol levels and helps assess cardiovascular risk, but it is not useful for diagnosing an acute MI.
Choice C rationale
An electrocardiogram (ECG) is essential for diagnosing an MI as it shows the heart's electrical activity and can indicate ischemia or infarction.
Choice D rationale
Troponin levels are the most specific and sensitive markers for myocardial infarction. Elevated troponin levels confirm heart muscle damage due to an MI, making it the definitive test.
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