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

Test her urine for the presence of haematuria.

Measure her temperature and heart rate.

Evaluate the urine for a strong Odor.

Palpate the right flank for tenderness.

Answer and Explanation

The Correct Answer is B

Choice A reason: Testing the urine for the presence of haematuria is important for diagnosing a urinary tract infection (UTI) or kidney stones, but it is not the most immediate intervention. Haematuria indicates blood in the urine, but assessing the client's vital signs is more urgent to determine if there is an acute issue that requires immediate attention.

Choice B reason: Measuring her temperature and heart rate is the most critical first step. These vital signs can provide immediate information about the client's overall condition and help identify potential systemic infection (fever) or hemodynamic instability (tachycardia). This information is essential for prioritizing further interventions and determining the urgency of the situation.

Choice C reason: Evaluating the urine for a strong Odor can help identify the presence of a UTI, but it is not as immediately critical as assessing the client's vital signs. Changes in urine Odor can support a diagnosis, but they do not provide the urgent information needed to assess the client's immediate health status.

Choice D reason: Palpating the right flank for tenderness is important for assessing kidney involvement, such as in cases of pyelonephritis (kidney infection). However, this physical examination should follow the assessment of vital signs to ensure the client is stable and not in immediate danger.

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Correct Answer is B

Explanation

Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.

Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.

Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.

Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.

Correct Answer is ["8"]

Explanation

Step 1: Convert the client's weight from pounds to kilograms. 176 pounds ÷ 2.2 = 80 kg

Step 2: Determine the total units of insulin needed per hour. 80 kg × 0.1 unit/kg/hour = 8 units/hour

Step 3: Determine the volume of insulin solution needed per hour. (8 units) ÷ (100 units/100 mL) = (8 units) ÷ (1 unit/mL) = 8 mL/hour

So, the nurse should set the infusion pump to deliver 8 mL/hour.

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

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Naxlex Comprehensive Predictor Exams

After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

Correct Answer is B

Explanation

Correct Answer is ["8"]

Explanation

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