After a change-of-shift report, which patient should the nurse assess first?
A patient with kidney stones who has not voided for 12 hours.
A patient with kidney stones who has blood in the urine.
A patient with a urinary tract infection (UTI) who has a fever of 100 degrees (37.7 Celsius).
A patient with a UTI who has cloudy urine.
The Correct Answer is A
Choice A rationale
Twelve hours without voiding indicates potential acute urinary retention due to ureteral obstruction, risking hydronephrosis or kidney damage, which requires immediate attention to preserve renal function.
Choice B rationale
Hematuria is common with kidney stones and generally not urgent unless accompanied by clots causing retention or excessive bleeding causing hemodynamic instability.
Choice C rationale
Fever indicates infection but at 37.7°C, it is considered low-grade and less urgent compared to obstruction. Normal body temperature is typically 36.1-37.2°C.
Choice D rationale
Cloudy urine suggests infection but lacks the immediacy of urinary retention or acute obstruction, which are potentially life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Keeping the patient NPO minimizes gastrointestinal motility and prevents further accumulation of intestinal contents, reducing the risk of perforation and worsening obstruction. Bowel rest is crucial in promoting resolution.
Choice B rationale
Nasogastric tube placement alleviates distention by decompressing the stomach and removing gastric contents, reducing vomiting and the risk of aspiration while improving patient comfort.
Choice C rationale
Rectal tubes are not effective in decompressing small bowel obstructions since the obstruction prevents material from reaching the rectum.
Choice D rationale
Frequent oral care prevents mucosal dryness and infection risk in patients who are NPO and receiving suction therapy, promoting overall oral hygiene.
Correct Answer is B
Explanation
Choice A rationale
Estimating carbohydrate content rather than measuring can lead to inaccuracies in blood sugar control for diabetic patients. Precise carbohydrate counting is essential for maintaining glycemic control and preventing hyperglycemia or hypoglycemia, making this approach unsuitable in diabetes education.
Choice B rationale
Balancing carbohydrate intake with insulin or medication is a critical aspect of diabetes management. This ensures stable blood glucose levels as insulin dosage or medication is adjusted according to the patient's carbohydrate consumption, providing personalized glycemic control effectively.
Choice C rationale
Avoiding all carbohydrates is not a realistic or scientifically sound recommendation, as carbohydrates are essential for energy production. Teaching portion control and healthy carbohydrate choices is more effective for diabetic management than complete avoidance.
Choice D rationale
Counting carbohydrates from sugary foods alone ignores the contribution of complex carbohydrates to blood glucose levels. A comprehensive approach that considers all sources of carbohydrates ensures accurate diabetes education and better long-term blood sugar control.
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