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
Avoiding bubble baths is a correct measure for preventing UTIs. Bubble baths can irritate the urethra and increase the risk of infection by allowing bacteria to enter the urinary tract. The warm, soapy water can disrupt the natural balance of bacteria in the genital area, making it easier for harmful bacteria to thrive and cause infections.
Choice B rationale
Voiding after sexual intercourse is a correct measure for preventing UTIs. During sexual activity, bacteria can be introduced into the urethra. By urinating after intercourse, the client can help flush out any bacteria that may have entered the urinary tract, reducing the risk of infection.
Choice C rationale
Wiping the perineal area from back to front after urination is incorrect and indicates the need for further teaching. This practice can transfer bacteria from the anal area to the urethra, increasing the risk of UTIs. The correct method is to wipe from front to back to prevent the spread of bacteria.
Choice D rationale
Drinking at least 8 full glasses of liquid each day is a correct measure for preventing UTIs. Adequate hydration helps flush bacteria from the urinary tract, reducing the risk of infection. Drinking plenty of fluids ensures that the bladder is emptied regularly, which helps prevent the buildup of bacteria.
Correct Answer is D
Explanation
Choice A rationale
Frothy sputum is more commonly associated with left-sided heart failure, where fluid backs up into the lungs. It is not a typical finding in right-sided heart failure.
Choice B rationale
Orthopnea, or difficulty breathing while lying flat, is more commonly associated with left-sided heart failure. Right-sided heart failure primarily affects the systemic circulation.
Choice C rationale
Dyspnea, or shortness of breath, can occur in both left-sided and right-sided heart failure. However, it is more prominently associated with left-sided heart failure.
Choice D rationale
Peripheral edema, or swelling in the legs and ankles, is a common finding in right-sided heart failure. It occurs due to the backup of blood in the systemic circulation, leading to fluid accumulation in the tissues.
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