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.
Prepare the client for a prescribed computed tomography (CT) scan.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B rationale:
Giving the wife a straw to help facilitate the client's drinking is not the most appropriate action in this situation. The client's facial paralysis and inability to move his left side could be indicative of a possible stroke or cerebral vascular accident (CVA). Before attempting to give the client fluids, it is essential to assess his swallowing reflex to prevent aspiration and ensure safety. Using a straw may not address the underlying issue.
Choice C rationale:
Assisting the wife and carefully giving the client small sips of water without assessing the swallowing reflex can be risky. If the client has impaired swallowing, this action could lead to aspiration and further complications. Assessing the client's ability to swallow is the priority to ensure safe oral intake.
Choice D rationale:
Obtaining thickening powder before providing any more fluids is premature without first assessing the client's swallowing ability. Thickened liquids may be necessary if the client has dysphagia, but the nurse should assess the client's condition and consult with the healthcare provider before making this decision. Assessing the swallowing reflex is the first step in determining the appropriate course of action.
Correct Answer is C
Explanation
Choice A rationale:
Domestic violence assistance is an important topic, but it falls under secondary and tertiary prevention rather than primary disease prevention, which is the focus of this community outreach program. Primary prevention aims to prevent the disease from occurring in the first place, while domestic violence assistance addresses an existing issue.
Choice B rationale:
Blood pressure screening is valuable for early detection of hypertension, but it also falls under secondary prevention. Primary prevention focuses on preventing the onset of diseases through measures such as immunizations, health education, and lifestyle modifications.
Choice D rationale:
Outreach for support group information is essential for clients with chronic conditions or specific needs. However, it is not primarily related to preventing diseases at the population level, which is the primary goal of this community outreach program. This topic may be more relevant to secondary and tertiary prevention efforts.
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