A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?
Apply cold compress to the client's flank area
Restrict protein intake to 2 servings per day.
Encourage intake of at least 3 L of fluids per day
Discourage ambulation
The Correct Answer is C
A. Apply cold compress to the client's flank area - Applying a warm compress, not a cold one, to the flank area can help alleviate pain associated with urolithiasis. Heat can promote muscle relaxation and increase blood flow to the area, potentially easing discomfort.
B. Restrict protein intake to 2 servings per day - There is no direct connection between protein intake and urolithiasis. However, specific dietary recommendations may vary based on the type of kidney stones a person has. For example, individuals with certain types of stones might be advised to limit oxalate-rich foods. It's essential to tailor dietary advice based on the composition of the stones.
C. Encourage intake of at least 3 L of fluids per day - Adequate fluid intake, particularly water, is crucial for preventing the formation of kidney stones. Increased fluid intake can help dilute substances in the urine that contribute to stone formation, reducing the risk of stone recurrence.
D. Discourage ambulation - Encouraging ambulation and movement is generally beneficial for patients with urolithiasis. Movement can help alleviate discomfort, prevent complications such as blood clots, and promote overall well-being. Restricting movement unnecessarily is not advisable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. There is no need for the client to lie flat for an extended period after a DEXA scan. The procedure is non-invasive and does not require immobilization.
B. Emptying the bladder before the test is essential to ensure a clear and accurate scan of the pelvis and lower spine. A full bladder might obstruct the view and affect the accuracy of the results.
C. DEXA scans do not typically require the use of IV dye. It is a simple X-ray procedure that measures bone density, and no contrast material is usually needed.
D. Fasting is not necessary for a DEXA scan. The procedure does not involve ingesting or injecting any substances that require fasting.
Correct Answer is D
Explanation
A. Chronic pain - Chronic pain is a concern for the client, but addressing the underlying issue of ineffective tissue perfusion will help alleviate pain by promoting healing and reducing tissue damage.
B. Impaired skin integrity - Impaired skin integrity is a result of ineffective tissue perfusion. By addressing perfusion issues, skin integrity can be improved as tissues receive adequate oxygen and nutrients for healing.
C. Risk for injury - While clients with arterial insufficiency ulcers are at risk for injury, the immediate concern is addressing the ineffective tissue perfusion to prevent complications related to poor circulation, such as tissue necrosis and infection.
D. Ineffective tissue perfusion- Arterial insufficiency ulcers are caused by inadequate blood flow to the tissues. The priority issue for a client with an arterial insufficiency ulcer is ineffective tissue perfusion. Due to decreased blood flow, tissues do not receive enough oxygen and nutrients, leading to delayed wound healing, tissue damage, and potential complications. Interventions should focus on improving circulation, promoting vasodilation, and enhancing perfusion to facilitate wound healing and prevent further tissue damage.
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