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.
Obtain clean catch urine for culture and sensitivity.
Initiate broad spectrum IV antibiotic as secondary infusion.
Collect a serum sample for hemoglobin and hematocrit.
Give diphenhydramine prep for intravenous pyelogram.
Force oral fluids to 2,000 mL/24 hours.
Correct Answer : A,B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The neurology unit supervisor oversees the neurology unit but does not typically coordinate individual patient care progression.
Choice B reason: The risk management nurse focuses on identifying and mitigating risks within the healthcare setting but does not coordinate patient care.
Choice C reason: An adult nurse practitioner may provide direct care but does not typically coordinate the overall progression of care.
Choice D reason: The nurse case manager is responsible for coordinating the patient's care plan, ensuring continuity of care, and managing transitions between different levels of care.
Correct Answer is C
Explanation
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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