A nurse is admitting a client who reports recurrent flank pain and nausea for 24 hr. Which of the following actions should the nurse take first?
Monitor intake and output.
Administer pain medication.
Ambulate in hall.
Strain the urine.
The Correct Answer is B
Choice A rationale
Monitoring intake and output is important but not the first priority. The immediate concern is to address the client’s pain.
Choice B rationale
Administering pain medication is the first priority. Managing the client’s pain will help alleviate discomfort and allow for further assessment and treatment.
Choice C rationale
Ambulating in the hall is not appropriate for a client experiencing flank pain and nausea. It could exacerbate the symptoms.
Choice D rationale
Straining the urine is important for identifying any stones, but it is not the first priority. Pain management should be addressed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A high protein diet is not recommended for clients with biliary colic from chronic cholecystitis as it can increase bile production and exacerbate symptoms.
Choice B rationale
A high fiber diet is beneficial for overall health but does not specifically address the needs of clients with biliary colic.
Choice C rationale
A low sodium diet is beneficial for overall health but does not specifically address the needs of clients with biliary colic.
Choice D rationale
A low fat diet is recommended for clients with biliary colic from chronic cholecystitis as it reduces the workload on the gallbladder and decreases the risk of gallstone formation.
Correct Answer is C
Explanation
Choice A rationale
Kernig’s sign is associated with meningitis, not hypocalcemia. It involves pain and resistance when attempting to extend the leg at the knee while the hip is flexed.
Choice B rationale
Brudzinski’s sign is also associated with meningitis, not hypocalcemia. It involves involuntary lifting of the legs when lifting a patient’s head.
Choice C rationale
Chvostek’s sign is a clinical sign of hypocalcemia. It involves twitching of the facial muscles in response to tapping over the facial nerve.
Choice D rationale
Cullen’s sign is associated with acute pancreatitis and involves bruising around the umbilicus. It is not related to hypocalcemia.
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