A client with renal calculi is experiencing hematuria and reports severe flank pain.
Which intervention should the nurse implement first?

Obtain a urine specimen for analysis.

Administer a prescribed opioid analgesic.

Strain the urine for the presence of stones.

Prepare the client for a prescribed computed tomography (CT) scan.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.

Choice B rationale:

This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.

Choice C rationale:

Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.

Choice D rationale:

Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.

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Correct Answer is A

Explanation

Choice A rationale:

Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.

Choice B rationale:

Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.

Choice C rationale:

While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.

Choice D rationale:

Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.

A. Ask questions in a vague, non-specific format. B. Begin with questions that are less sensitive in nature. C. Get the most difficult questions over with first. D. Share personal values to put the client at ease.

Correct Answer is B

Explanation

Choice A rationale:

Asking questions in a vague, non-specific format is not the best approach for addressing intimate partner violence. This approach may confuse the client or make them feel uncomfortable, as they may not know what specific information the nurse is seeking. It is essential to use clear and direct communication when addressing sensitive issues like intimate partner violence.

Choice B rationale:

Beginning with questions that are less sensitive in nature is the preferred approach when interviewing a client about intimate partner violence. This allows the nurse to establish rapport and build trust with the client before delving into more sensitive topics. Starting with less sensitive questions can help the client feel more comfortable and willing to share information about their situation.

Choice C rationale:

Getting the most difficult questions over with first is not the best approach when addressing intimate partner violence. Starting with the most challenging questions may cause the client to become defensive or unwilling to cooperate. It is essential to build a therapeutic relationship before discussing sensitive topics to ensure the client's emotional safety and willingness to disclose information.

Choice D rationale:

Sharing personal values to put the client at ease is not an appropriate approach when addressing intimate partner violence. It can be perceived as unprofessional and may compromise the objectivity and neutrality of the nurse in providing care. The focus should be on the client's needs and concerns, not the nurse's personal beliefs.

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A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

What are some important nursing considerations for this medication? *.

Correct Answer is A

Explanation

Which is the best approach for the nurse to use when interviewing a client about intimate partner violence?

Correct Answer is B

Explanation

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A client with renal calculi is experiencing hematuria and reports severe flank pain.
Which intervention should the nurse implement first?