A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Palpate the right flank for tenderness.

Test the urine for the presence of hematuria.

Evaluate the urine for a strong odor.

Measure the temperature and pulse rate.

Answer and Explanation

The Correct Answer is D

A. Palpating the right flank for tenderness is essential to assess for possible renal involvement, such as a kidney infection or kidney stone, which could be causing the urinary symptoms and right lower back pain. However, it is not the initial step.

B. Testing the urine for the presence of hematuria is important in assessing for potential urinary tract infection or other renal pathology but does not directly address the cause of the right lower back pain.

C. Evaluating the urine for a strong odor may provide information about a possible urinary tract infection, but it is not the most immediate intervention for addressing the client's symptoms, compared to measuring the vital signs.

D. Measuring the temperature and pulse rate is important for identifying any signs of systemic infection or inflammation that could be contributing to the patient's symptoms.

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Correct Answer is ["125"]

Explanation

To calculate the infusion rate in mL/hr, you would convert the total volume of lactated Ringer's IV from liters to milliliters (since there are 1,000 milliliters in a liter, 3 liters is equivalent to 3,000 milliliters) and then divide by the total number of hours over which the infusion is to be administered. In this case, 3,000 mL divided by 24 hours results in an infusion rate of 125 mL/hr.

A. Collect the blood sample. B. Select another finger. C. Apply pressure to the site. D. Assess radial pulse volume.

Correct Answer is B

Explanation

A. Collecting the blood sample from a reddened and engorged fingertip may lead to inaccurate glucose readings and can cause discomfort to the client. Selecting another finger is a more appropriate action.

B. Selecting another finger ensures an accurate blood sample and minimizes discomfort to the client. It allows for a fresh puncture site that is not engorged, improving the accuracy of the glucose reading.

C. Applying pressure to the site may temporarily reduce engorgement but may not be sufficient to obtain an accurate blood sample. Selecting another finger is a more appropriate action.

D. Assessing radial pulse volume is not necessary in this situation, as the client's fingertip appearance does not indicate compromise of peripheral circulation.

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A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only)

Correct Answer is ["125"]

Explanation

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

Correct Answer is B

Explanation

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