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

Evaluate the urine for a strong odor.

Measure her temperature and pulse rate

Test her urine for the presence of hematuria.

Palpate the right flank for tenderness

Answer and Explanation

The Correct Answer is B

A. Evaluate the urine for a strong odor.
While evaluating urine for a strong odor can provide some information about a possible urinary tract infection (UTI), it is not the most immediate concern. The priority in this case is to assess for signs of systemic infection, and checking for a strong odor can be done later.

B. Measure her temperature and pulse rate.
This is the correct choice. Measuring temperature and pulse rate is a critical initial step to assess for signs of systemic infection. Fever and an elevated pulse rate can indicate that the infection may have spread beyond the bladder, possibly involving the kidneys.

C. Test her urine for the presence of hematuria.
Testing for hematuria (blood in the urine) is an important diagnostic step for a UTI, but it is not the first priority. Vital sign assessment takes precedence to determine the severity of the condition and the need for urgent intervention.

D. Palpate the right flank for tenderness.
Palpating the right flank for tenderness is a relevant physical assessment to check for kidney involvement, which is important in cases of suspected pyelonephritis. However, assessing vital signs is a more immediate and critical step to determine the severity of the condition.

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Correct Answer is D

Explanation

A. Measure the client's blood pressure:
While monitoring blood pressure is an important aspect of assessing a client's overall condition, it is not the immediate priority in a suspected opioid overdose. Respiratory depression and difficulty in arousing are more critical concerns that warrant prompt intervention with naloxone.

B. Remove all of the morphine patches:
While eventually, the nurse will need to address the presence of multiple morphine patches, removing them is not the first action. Administering naloxone to reverse the opioid effects takes precedence over patch removal.

C. Apply oxygen per face mask:
While providing oxygen may be necessary to support respiratory function, it doesn't address the underlying cause of the respiratory distress, which is likely opioid toxicity. Administering naloxone is the more direct and immediate intervention to counteract the effects of the opioids.

D. Administer a narcotic antagonist:
This is the correct and immediate priority. If the client is difficult to arouse and has multiple morphine patches, it raises concerns about opioid toxicity. Naloxone is a narcotic antagonist that can reverse the effects of opioid overdose, particularly respiratory depression, and is crucial in this scenario to restore normal respiratory function.

A. Return appointments will be needed for IV medication. B. Wearing gloves when handling cold items guards against painful spasms. C. Enrolling in a pain clinic can provide pain relief alternatives D. Painful areas should be rubbed gently until the pain subsides.

Correct Answer is B

Explanation

A. Return appointments will be needed for IV medication:
This statement does not address the specific concern related to pain management in Raynaud's disease, and routine IV medication may not be the primary approach for pain relief in this condition.

B. Wearing gloves when handling cold items guards against painful spasms:
This is the correct answer. Raynaud's disease is characterized by vasospasm of small arteries, often triggered by exposure to cold or stress. Wearing gloves helps to minimize exposure to cold and can prevent painful spasms associated with Raynaud's.

C. Enrolling in a pain clinic can provide pain relief alternatives:
While pain clinics can offer various pain management strategies, the specific recommendation for Raynaud's disease involves minimizing exposure to cold and stress rather than enrolling in a pain clinic.

D. Painful areas should be rubbed gently until the pain subsides:
Rubbing painful areas may not be recommended, as it can potentially aggravate vasospasm in individuals with Raynaud's disease. The emphasis is on preventing triggers like cold exposure.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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