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 ["A","B"]

Explanation

Choice A reason: Obtaining a clean catch urine sample for culture and sensitivity is crucial for identifying the specific bacteria causing the infection and determining the appropriate antibiotic treatment.

Choice B reason: Initiating broad spectrum IV antibiotics is important to start treating the infection immediately, especially given the severity of the symptoms.

Choice C reason: Collecting a serum sample for hemoglobin and hematocrit is not immediately necessary in this scenario. The focus should be on diagnosing and treating the infection.

Choice D reason: Giving diphenhydramine prep for intravenous pyelogram is not relevant to the immediate management of the client's condition.

Choice E reason: Forcing oral fluids can help flush out the urinary system, but it is not the most critical initial intervention compared to obtaining a urine culture and starting antibiotics.

A. Sedimentation rate B. Anti-cyclic citrullinated peptide (anti-CCP) antibodies C. D-Dimer D. C-reactive protein E. White blood cell count

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: The sedimentation rate (ESR) is a common test used to detect inflammation associated with conditions such as rheumatoid arthritis. An elevated ESR indicates the presence of inflammation in the body.

Choice B reason: Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for rheumatoid arthritis and are useful in confirming the diagnosis. The presence of these antibodies can help distinguish RA from other inflammatory conditions.

Choice C reason: D-Dimer is primarily used to rule out thrombotic conditions such as deep vein thrombosis and pulmonary embolism. It is not specifically related to the diagnosis or management of rheumatoid arthritis.

Choice D reason: C-reactive protein (CRP) is another marker of inflammation that is often elevated in rheumatoid arthritis. It provides information about the level of inflammation and can be used to monitor disease activity and response to treatment.

Choice E reason: While a white blood cell count can provide general information about infection or inflammation, it is not specific to rheumatoid arthritis and is not as useful as the other tests mentioned for diagnosing or managing RA.

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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

An adult is admitted with acute flank pain, a 102°F (38.9°C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.

Correct Answer is ["A","B"]

Explanation

Correct Answer is ["A","B","D"]

Explanation

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