A client is admitted with urolithiasis and reports severe flank pain rated 9/10 with nausea and vomiting.
The client has not voided in 6 hours. Which nursing action is the priority?
Instruct the client to strain all urine.
Encourage oral fluid intake.
Administer prescribed opioid analgesic.
Assess for bladder distention and attempt to obtain a urine sample.
The Correct Answer is D
This case focuses on managing urolithiasis with signs of potential urinary obstruction. Knowledge of the nursing process, prioritization of physiological needs, and the distinction between pain management and critical organ perfusion/output is necessary to determine the first action.
Choice A rationale
Straining urine is important for stone analysis but is not the immediate priority for a client who hasn't voided in 6 hours. Assessment of the underlying cause of urinary retention must occur before focusing on stone recovery procedures.
Choice B rationale
Encouraging fluids helps flush stones but may exacerbate pain or vomiting if a total obstruction is present. The client's lack of output for 6 hours requires an assessment of bladder status before increasing fluid load significantly.
Choice C rationale
Pain management is essential for urolithiasis, but the lack of urinary output is a physiological priority. Assessing for bladder distention or obstruction ensures the kidneys are not sustaining damage from hydronephrosis before focusing solely on symptomatic relief.
Choice D rationale
Assessing for bladder distention is the priority to determine if the client is experiencing urinary retention due to obstruction. Identifying whether urine is being produced but trapped in the bladder is critical for preventing renal injury and hydronephrosis..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Endotracheal suctioning carries risks of hypoxia and vagal stimulation. Knowledge of respiratory physiology and emergency protocols is required to recognize when a procedure is causing clinical instability and to prioritize the immediate restoration of oxygenation and cardiac rhythm stability.
Choice A rationale
Tachycardia, arrhythmias, and desaturation during suctioning indicate acute hypoxia and myocardial stress. The nurse must stop the procedure immediately to prevent cardiac arrest and provide 100 percent oxygen to restore alveolar gas exchange and stabilize the heart rate.
Choice B rationale
Continuing the procedure while the patient is experiencing cardiac instability and severe hypoxia is dangerous. Prolonged suctioning increases the risk of further vagal stimulation and worsening hypoxemia, which could lead to fatal arrhythmias or sudden respiratory and cardiac collapse.
Choice C rationale
While the provider needs to be informed, it is not the priority. Immediate life saving intervention, such as stopping suctioning and hyper-oxygenating the client, must occur first to address the physiological distress and prevent further deterioration of the client.
Choice D rationale
Antiarrhythmics are not the first line treatment for suction induced arrhythmias. These rhythm changes are usually a direct result of hypoxia. Correcting the underlying oxygen deficiency by stopping the suction and providing supplemental oxygen usually resolves the tachycardia and irregularity..
Correct Answer is A
Explanation
The clinical scenario involves a client experiencing neurological deficits from a transient ischemic attack who presents with specific pharmacological and chemical allergies. Applying knowledge of cross-sensitivity and radiopaque dye composition is essential to identify risks associated with iodine-based contrast media and morphine-codeine hypersensitivity.
Choice A rationale
Computed tomography scans with contrast utilize iodine-based dyes to enhance vascular visualization. Since the client has a documented iodine allergy, this order poses a significant risk of anaphylaxis or severe hypersensitivity reactions and requires urgent clarification with the provider.
Choice B rationale
Transient ischemic attacks are often linked to atherosclerosis and hypertension. A low-fat, low-cholesterol diet is a standard therapeutic intervention to manage lipid levels and prevent further plaque accumulation, making this a safe and appropriate non-pharmacological order.
Choice C rationale
Monitoring vital signs is a fundamental nursing responsibility during the acute phase of a neurological event. Frequent assessments help detect changes in blood pressure or heart rate, which are critical for maintaining cerebral perfusion and identifying potential deterioration.
Choice D rationale
Acetaminophen is a non-opioid analgesic that does not share chemical properties with morphine or codeine. Because it is not an opiate or salicylate, it is safe to administer for a headache in a patient allergic to opioids.
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