The nurse is caring for a client with urolithiasis who reports severe flank and abdominal pain. Which action should the nurse implement?

Maintain client on strict bedrest.

Limit fluid intake.

Strain all urine.

Answer and Explanation

The Correct Answer is C

Choice A reason: Strict bedrest is not indicated for urolithiasis, as movement may aid stone passage by shifting ureteral dynamics. Severe flank pain from ureteral obstruction causes muscle spasms. Straining urine collects stones for analysis, identifying composition to guide treatment, making bedrest less critical than addressing the stone.

Choice B reason: Limiting fluid intake is contraindicated, as high fluids promote urine flow, aiding stone passage and diluting urinary solutes like calcium. Pain results from obstruction, and straining urine identifies stone type. Fluid restriction increases stone formation risk, making this harmful and counterproductive to urolithiasis management.

Choice C reason: Straining all urine collects stones for analysis, determining composition (e.g., calcium oxalate) to guide dietary and pharmacological prevention. Severe flank pain from ureteral obstruction highlights the need for stone identification. This addresses the pathophysiological cause, enabling tailored interventions to prevent recurrence and manage acute symptoms.

Choice D reason: A high-calcium diet is inappropriate, as most kidney stones are calcium-based. Dietary calcium moderation, based on stone analysis from straining urine, prevents recurrence. Pain management requires stone identification, not increased calcium intake, which could exacerbate stone formation, making this counterproductive for urolithiasis.

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Correct Answer is C

Explanation

Choice A reason: Monitoring serum potassium is relevant, as lisinopril can cause hyperkalemia by reducing aldosterone, impairing potassium excretion. Skin turgor, however, assesses hydration, not ACE inhibitor effects. Blood pressure monitoring is more critical, as lisinopril lowers blood pressure via vasodilation, risking hypotension and falls, especially in elderly clients.

Choice B reason: Eosinophil count and constipation are unrelated to lisinopril’s effects. Elevated eosinophils may suggest allergies, but this is rare with ACE inhibitors. Constipation is not a common side effect. Lisinopril’s primary action is renin-angiotensin inhibition, making blood pressure and fall risk monitoring more urgent to prevent hypotensive complications.

Choice C reason: Lisinopril reduces angiotensin II, promoting vasodilation and lowering blood pressure. Monitoring blood pressure detects hypotension, which increases fall risk, particularly in older adults, due to dizziness or orthostatic changes. This directly assesses the drug’s cardiovascular effects, ensuring safety by preventing falls or syncope, making it the priority assessment.

Choice D reason: Heart rate and nausea are not primary lisinopril concerns. Tachycardia may occur secondary to hypotension, and nausea is rare. The drug’s main effect is blood pressure reduction via ACE inhibition, necessitating monitoring for hypotension and fall risk to ensure patient safety, as these are more immediate and significant pharmacological effects.

A. Question the client about related symptoms. B. Palpate the inguinal area for a bulge. C. Inspect the urethral meatus for abnormalities. D. Observe the scrotum for swelling.

Correct Answer is A

Explanation

Choice A reason: Questioning about related symptoms (e.g., urgency, frequency) clarifies nocturia and hesitancy, suggesting causes like benign prostatic hyperplasia. This comprehensive data guides targeted assessments, ensuring accurate diagnosis and treatment, per urological assessment and patient history standards in elderly male nursing care.

Choice B reason: Palpating for an inguinal bulge assesses hernia, unrelated to nocturia or hesitancy. Questioning related symptoms better identifies urinary issues, guiding diagnosis. Hernias are not primary causes, per urological assessment and differential diagnosis protocols in nursing care for urinary complaints.

Choice C reason: Inspecting the meatus for abnormalities or discharge may follow but is less comprehensive than symptom questioning, which broadens the urinary history. Symptoms like hesitancy suggest internal issues, per urological assessment and benign prostatic hyperplasia diagnostic standards in nursing practice for elderly men.

Choice D reason: Observing scrotal swelling assesses testicular issues, not directly linked to nocturia or hesitancy. Questioning symptoms like weak stream or dribbling prioritizes urinary tract evaluation, per urological and geriatric assessment protocols in nursing care for male urinary symptoms.

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The nurse is caring for a client with urolithiasis who reports severe flank and abdominal pain. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

Correct Answer is C

Explanation

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

Correct Answer is A

Explanation

Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?

Which client’s laboratory value requires immediate intervention by a nurse? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?

At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].

A client who has been hospitalized with an exacerbation of heart failure experiences severe dyspnea with activity and remains on bedrest. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?