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 C
Explanation
A. Increased thickness of the subcutaneous skin layer - Aging typically results in thinning of the skin and subcutaneous tissue, making older adults more vulnerable to pressure ulcers rather than having increased thickness.
B. Changes in the character and quantity of bacterial skin flora - This is a common age-related change; however, it is not directly related to the course of treatment for a sacral pressure ulcer. Proper wound care can mitigate the impact of changes in skin flora.
C. Increased time required for wound healing - Aging often leads to a decline in the body's ability to repair and regenerate tissues, which can prolong the healing process of wounds, including pressure ulcers. Older adults may experience delayed wound healing compared to younger individuals.
D. Increased elasticity of the skin - Skin elasticity decreases with age, making older adults more susceptible to skin breakdown and pressure ulcers due to reduced skin resilience and ability to redistribute pressure. Increased elasticity would not affect the course of treatment positively but rather negatively in this context.
Correct Answer is ["B","C","D","E"]
Explanation
A. Malunion: Malunion happens when a fractured bone heals in an improper position, leading to deformity and functional impairment. While it is a concern, it typically develops over time during the healing process and is not an immediate early complication that the nurse would monitor for in the acute phase following a fracture.
B. Compartment syndrome: Compartment syndrome is a serious condition that can occur after an injury, such as a fracture. When there is increased pressure within a muscle compartment, it can lead to reduced blood flow, potentially causing tissue damage and nerve injury. Prompt recognition and intervention are crucial to prevent complications.
C. Fat embolism: Fat embolism occurs when fat particles from the bone marrow or other sources enter the bloodstream, often after a long bone fracture or major trauma. These particles can travel to the lungs and other organs, causing respiratory distress, confusion, and other symptoms. Fat embolism is a significant concern in orthopedic trauma patients and requires careful monitoring.
D. Deep vein thrombosis (DVT): DVT is the formation of blood clots in deep veins, usually in the legs. Patients with fractures, especially those immobilized for extended periods, are at increased risk for DVT. If a clot dislodges and travels to the lungs, it can cause a pulmonary embolism, which is a life-threatening complication.
E. Pulmonary emboli: Pulmonary emboli occur when blood clots, often originating from DVT, travel to the lungs and block pulmonary arteries. This condition can lead to sudden difficulty breathing, chest pain, and even cardiac arrest. Pulmonary embolism is a medical emergency and requires immediate intervention.
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