The nurse is caring for a hospitalized client who is attempting to pass a kidney stone. Which clinical manifestation should the nurse recognize as Indicating a potential emergency situation?

Renal colic

Hematuria in urinalysis

Nausea

Anuria

Answer and Explanation

The Correct Answer is D

D. Anuria refers to the absence of urine production, which can occur due to urinary tract obstruction, severe dehydration, or renal failure. In the context of a client attempting to pass a kidney stone, anuria would be a concerning sign indicating potential urinary tract obstruction requiring urgent medical attention.
A. Renal colic refers to severe flank pain caused by the passage of a kidney stone through the urinary tract. While renal colic is a common symptom of kidney stones and can cause significant discomfort, it does not necessarily indicate an emergency situation unless it is associated with complications such as obstructive uropathy or infection.
B. Hematuria, or blood in the urine, is a common finding in individuals with kidney stones. It occurs due to irritation or injury to the urinary tract as the stone passes through.
C. Nausea is a common symptom experienced by individuals with kidney stones, particularly if there is associated pain or discomfort. While nausea can be distressing, it does not typically indicate an emergency situation unless it is severe and persistent, leading to dehydration or other complications.

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Correct Answer is A

Explanation

A. Magnesium hydroxide is an antacid medication that works by neutralizing gastric acid in the stomach. Therefore, if the medication achieves the desired therapeutic effect, the nurse should expect neutralization of gastric acid, which can alleviate the burning sensation in the esophagus associated with GERD.
B. Magnesium hydroxide does not directly affect stomach motility. Instead, its primary action is to neutralize gastric acid. Therefore, reducing stomach motility is not an expected outcome of magnesium hydroxide administration.
C. Magnesium hydroxide primarily acts within the stomach to neutralize gastric acid and does not significantly affect the pH of the duodenum. Therefore, reduced duodenal pH is not an expected outcome of magnesium hydroxide administration.
D. Pepsin is an enzyme involved in the digestion of proteins and can contribute to tissue damage if refluxed into the esophagus. Although reducing gastric acidity can indirectly decrease the activity of pepsin, magnesium hydroxide does not directly increase the barrier to pepsin.

A. Sit the client up and provide supplemental oxygen B. Contact the physician and obtain an arterial blood gas C. Explain that this is an expected finding after surgery D. Encourage the use of the incentive spirometer

Correct Answer is A

Explanation

A. Sit the client up and provide supplemental oxygen is the correct priority intervention. Chest pain and shortness of breath can be indicative of pulmonary embolism or other respiratory complications, which require immediate attention. Sitting the client up helps improve respiratory mechanics, and providing supplemental oxygen can support oxygenation while further assessments are conducted.
B. While contacting the physician and obtaining an arterial blood gas may be necessary to assess respiratory status and oxygenation, it is not the immediate priority. The client's symptoms require immediate intervention to ensure adequate oxygenation and prevent further deterioration.
C. Chest pain and shortness of breath are not typically expected findings after bariatric surgery and could indicate serious complications. It is essential not to dismiss the client's symptoms but to take them seriously and initiate appropriate interventions.
D. While the use of an incentive spirometer is important for preventing respiratory complications after surgery, it is not the priority intervention in this situation. The client's current symptoms require immediate attention to address potential respiratory distress or other serious complications.

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The nurse is caring for a hospitalized client who is attempting to pass a kidney stone. Which clinical manifestation should the nurse recognize as Indicating a potential emergency situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is assessing a client after bariatric surgery. The client complains of chest pain and shortness of breath. What is the priority nursing Intervention at this time?

Correct Answer is A

Explanation

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