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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Potassium iodide is used to treat hyperthyroidism and protect the thyroid gland from radiation, but it does not help lower serum potassium levels.
Choice B rationale
Lactulose is a laxative used to treat constipation and hepatic encephalopathy, but it does not affect serum potassium levels.
Choice C rationale
Sodium polystyrene sulfonate is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, thereby lowering serum potassium levels.
Choice D rationale
Acetylcysteine is used as a mucolytic agent and to treat acetaminophen overdose, but it does not have any effect on serum potassium levels.
Correct Answer is D
Explanation
Choice A rationale
Providing a low protein diet is incorrect. Clients with COPD often require a high-protein diet to maintain muscle mass and support respiratory function. Protein is essential for the repair and maintenance of body tissues, including respiratory muscles. A low-protein diet could lead to muscle wasting and decreased respiratory function.
Choice B rationale
Instructing the client to cough every 4 hours is incorrect. Clients with COPD should be encouraged to perform controlled coughing techniques more frequently to clear secretions and prevent respiratory infections. Coughing every 4 hours may not be sufficient to maintain airway patency and prevent complications.
Choice C rationale
Advising the client to lie down after eating is incorrect. Clients with COPD should avoid lying down immediately after eating to prevent gastroesophageal reflux, which can exacerbate respiratory symptoms. Instead, they should remain upright for at least 30 minutes after meals to aid digestion and reduce the risk of aspiration.
Choice D rationale
Encouraging the client to drink 8 glasses of water a day is correct. Adequate hydration helps to thin mucus secretions, making them easier to expectorate. This can improve airway clearance and reduce the risk of respiratory infections. Additionally, staying hydrated supports overall health and well-being.
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