A nurse is caring for a patient with long history of chronic obstructive pulmonary disease (COPD) who develops cor pulmonale.
The nurse should monitor the patient for which expected finding if heart failure is present?

Choice A rationale

Preparing the client for lithotripsy is important for treatment but is not the immediate highest priority in an emergency setting. Immediate pain management takes precedence.

Choice B rationale

Ordering a renal ultrasound is necessary for assessing the stones but comes after stabilizing the client's acute symptoms, including managing pain.

Choice C rationale

Administering pain medication as prescribed is the highest priority because renal colic causes severe pain. Immediate pain relief is crucial for the client's comfort and to facilitate further diagnostic and therapeutic interventions.

Choice D rationale

Initiating IV fluid therapy is important for hydration and possibly aiding stone passage but follows after addressing the acute pain.

Choice A rationale

Administering a laxative is not necessary for a CT scan of the abdomen with contrast. Laxatives are typically used for bowel preparation for procedures like colonoscopies.

Choice B rationale

Biguanide medications such as metformin should be held before and after the administration of contrast medium to prevent lactic acidosis, particularly in clients with liver disease.

Choice C rationale

Fasting for 24 hours is not required before a CT scan with contrast medium. Typically, clients are asked to fast for a few hours prior to the procedure.

Choice D rationale

Ensuring the client is adequately hydrated helps to protect kidney function and reduce the risk of contrast-induced nephropathy. Hydration is especially important for clients with a history of liver disease.