A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Activity intolerance.

Fluid volume excess.

Ineffective airway clearance.

Altered nutrition; less than body requirements.

Answer and Explanation

The Correct Answer is C

Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.

Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.

Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.

Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.

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Correct Answer is C

Explanation

Choice A reason: Mononucleosis typically presents with fever, sore throat, and lymphadenopathy but does not commonly cause a rash on the hands and feet.

Choice B reason: Herpes simplex virus usually causes painful vesicular lesions rather than a diffuse rash on the hands and feet.

Choice C reason: Syphilis can present with a fever, sore throat, and a characteristic rash on the hands, palms, and soles of the feet, particularly in the secondary stage of the infection.

Choice D reason: Toxic shock syndrome is associated with high fever, rash, and shock, but the rash is not typically confined to the hands and feet.

A. Observe the appearance of the client's urine. B. Measure the girth of the client's lower abdomen. C. Auscultate an area six inches below the umbilicus. D. Palpate the area above the pubic symphysis.

Correct Answer is D

Explanation

Choice A reason: Observing the appearance of urine can provide information but is not the most direct assessment for urinary retention.

Choice B reason: Measuring the girth of the lower abdomen is not a specific assessment for urinary retention.

Choice C reason: Auscultation is not a reliable method for assessing urinary retention.

Choice D reason: Palpating above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

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A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect?

Correct Answer is C

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is D

Explanation

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