A client with a renal calculus reports severe right flank pain, nausea, and vomiting.
Which nursing problem has the highest priority?

Acute pain related to renal calculus.

Nutritional deficit related to nausea.

Impaired renal function related to pain.

Risk for aspiration related to vomiting.

Answer and Explanation

The Correct Answer is D

A. Acute pain related to renal calculus is important and needs to be addressed, but managing potential life-threatening conditions, like aspiration, takes precedence.

B. Nutritional deficit related to nausea is also a concern but is not as urgent as preventing aspiration.

C. Impaired renal function related to pain could be important in the long term, but it does not pose an immediate risk like aspiration does. Therefore, it is not the highest priority.

D. Risk for aspiration related to vomiting is the highest priority because it addresses the immediate potential for airway compromise, which can be life-threatening if the client aspirates vomitus. Ensuring the airway is protected and that aspiration does not occur is critical.

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Correct Answer is C

Explanation

A. Discontinuing the infusion of the solution may compromise the effectiveness of continuous bladder irrigation, which is typically indicated after TURP to prevent clot retention and ensure urinary drainage.

B. Manual irrigation of the catheter may disrupt the established irrigation system and lead to further complications. It is not the initial action to take in this situation.

C. Monitoring catheter drainage allows the nurse to assess the effectiveness of bladder irrigation and the presence of clot formation. Continued observation is necessary to ensure adequate drainage and identify any signs of complications.

D. Decreasing the flow rate may not address the underlying issue of clot retention and may not be appropriate without further assessment of the client's condition.

A. Bronze pigmentation. B. Lower leg edema. C. Uneven hair distribution. D. Bounding peripheral pulse.

Correct Answer is C

Explanation

A. Bronze pigmentation is not typically associated with compromised peripheral arterial circulation but may be seen in conditions like hemochromatosis.

B. Lower leg edema is more commonly associated with venous insufficiency rather than compromised arterial circulation.

C. Uneven hair distribution, such as decreased hair growth on the lower extremity, is indicative of compromised peripheral arterial circulation due to reduced blood flow to the area.

D. Bounding peripheral pulse is not typically associated with compromised peripheral arterial circulation but may indicate increased stroke volume or arterial stiffness.

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A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

Correct Answer is C

Explanation

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A client with a renal calculus reports severe right flank pain, nausea, and vomiting.
Which nursing problem has the highest priority?