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 the metabolic panel detects antibiotic side effects like renal toxicity, but this is ongoing. Collecting blood cultures first identifies the HAP pathogen, ensuring targeted therapy. Premature antibiotics may obscure results, leading to resistance, making cultures more urgent for effective treatment of this nosocomial infection.

Choice B reason: Nebulizer treatments aid airway clearance in HAP, but identifying the pathogen via cultures is critical before antibiotics. Ineffective therapy delays recovery, as bacteria proliferate in mucus. Cultures guide precise antibiotic selection, reducing resistance risk, making this less immediate than obtaining microbiological data.

Choice C reason: Collecting blood cultures before antibiotics identifies the HAP pathogen (e.g., MRSA) and its sensitivity, critical for tailoring therapy. Broad-spectrum antibiotics can yield false-negative cultures, complicating treatment. This ensures accurate diagnosis, optimizing outcomes in severe infections, addressing the microbiological basis of HAP management.

Choice D reason: Reviewing chest x-ray confirms HAP with infiltrates but does not guide immediate antibiotic therapy. Cultures are urgent to identify the pathogen before antibiotics, as x-rays are non-specific and already documented. Cultures ensure pathogen-specific treatment, critical for combating hospital-acquired infections effectively.

A. Cut the nails straight across, then soak the feet for 10 minutes in an antibiotic solution. B. Check the client’s feet for cuts or injury, then refer to a foot specialist for nail trimming. C. Soak the feet in warm water for 5 minutes, then cut the nails straight across. D. Advise the client to soften the nails with lotion prior to cutting them.

Correct Answer is B

Explanation

Choice A reason: Cutting nails and soaking in antibiotic solution risks infection in insulin-dependent diabetes, where neuropathy impairs sensation and healing. Thick nails may be fungal, needing specialist care. Checking for injuries and referring to a podiatrist ensures safe management, preventing ulcers in high-risk diabetic feet.

Choice B reason: Checking for cuts assesses diabetic foot risk, as neuropathy and poor glycemic control impair healing. Thick nails piercing toes require podiatrist trimming to prevent trauma or infection. Referral ensures expert care, addressing pathophysiological risks of neuropathy and vascular impairment, preventing serious complications like ulcers.

Choice C reason: Soaking and cutting nails is risky in diabetes, as neuropathy increases injury risk, and warm water may introduce infection in unnoticed wounds. Fungal nails need specialist care. Referral to a podiatrist ensures safe trimming, preventing infection in compromised feet, making this action unsafe.

Choice D reason: Advising lotion to soften nails does not mitigate injury risk from trimming thick nails in diabetes. Neuropathy and poor healing increase infection risk from errors. Specialist referral ensures safe nail management, preventing trauma or ulceration, critical in diabetic foot care due to vascular deficits.

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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?

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Naxlex Comprehensive Predictor Exams

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