A 45-year-old male client presents to the emergency department complaining of sudden onset of severe right flank pain radiating to the groin. He describes the pain as sharp and reports nausea. Vital signs reveal a heart rate of 110 bpm and elevated blood pressure. Urinalysis shows microscopic hematuria. Which nursing action is the priority for this client?

Encourage oral fluids to flush the urinary tract.

Administer analgesics for pain relief.

Monitor for signs of infection.

Notify the provider immediately for further evaluation.

Answer and Explanation

The Correct Answer is B

Choice A reason: While encouraging oral fluids is important in managing urinary tract conditions and preventing stone formation, it is not the immediate priority in a client experiencing acute, severe pain. Pain management must precede hydration efforts.

Choice B reason: The client is experiencing acute renal colic, likely due to a kidney stone, as suggested by flank pain and hematuria. The priority is to relieve pain, which can be excruciating and may cause hemodynamic instability. Prompt administration of analgesics is essential.

Choice C reason: Monitoring for infection is a standard nursing intervention, but there is no current evidence of infection such as fever or leukocytosis. Pain control takes precedence in this acute presentation.

Choice D reason: While notifying the provider is necessary for diagnostic imaging and further management, it is not the first action. Immediate pain relief should be initiated to stabilize the client before further evaluation.

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Correct Answer is B

Explanation

Choice A reason: Pudendal nerve damage is rare and typically associated with prolonged lithotomy positioning during surgery, not with postoperative sitting.

Choice B reason: Prolonged immobility increases the risk of venous thromboembolism, especially after pelvic surgery. Encouraging movement and avoiding extended sitting helps prevent deep vein thrombosis and pulmonary embolism.

Choice C reason: Pelvic organ prolapse is a long-term complication related to weakened pelvic floor muscles, not directly caused by sitting postoperatively.

Choice D reason: Hemorrhage is an acute postoperative risk but is not typically linked to sitting. It is more associated with surgical technique and early activity.

A. Iron deficiency anemia B. Pernicious anemia C. Hemolytic anemia D. Sickle cell disease

Correct Answer is A

Explanation

Choice A reason: Iron deficiency anemia is characterized by fatigue, low serum iron and ferritin, and pica—cravings for non-nutritive substances like ice or dirt. These findings align directly with the client’s symptoms.
Choice B reason: Pernicious anemia is caused by vitamin B12 deficiency and presents with neurological symptoms and macrocytic anemia, not pica or low ferritin.
Choice C reason: Hemolytic anemia involves destruction of red blood cells and typically presents with jaundice, dark urine, and elevated bilirubin—not low iron or pica.
Choice D reason: Sickle cell disease is a genetic disorder with vaso-occlusive crises and hemolysis, but it does not present with low iron or cravings for non-food items.

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Naxlex Comprehensive Predictor Exams

A client is being discharged home after a hysterectomy. When providing discharge education, the nurse cautions the client against sitting for long periods. This advice addresses the risk of what surgical complication?

Correct Answer is B

Explanation

A client presents with fatigue. During the health interview, the patient reports craving substances that are not typically considered food. Laboratory findings reveal low serum iron and ferritin levels. What would the nurse expect the client to be diagnosed with?

Correct Answer is A

Explanation

The nurse is caring for a client admitted with a diagnosis of Crohn's disease. When reviewing the client's most recent laboratory report, the nurse notes that the client's magnesium levels are low. The nurse should prioritize assessment for which health problem?

A client activated the call light to inform the nurse of sudden onset of lower leg pain. On assessment, the left leg is visibly swollen and reddened. Which action by the nurse is most appropriate?

A nurse is administering warfarin to a client with deep vein thrombosis (DVT). Which laboratory value would most reliably indicate that warfarin is at therapeutic levels?

A 56-year-old client has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, “My pressure has never been this high. Will the health care provider prescribe medication to reduce it?” What is the nurse’s best response?

A nurse is providing dietary teaching to a client with a history of recurring kidney stones. Which instruction should the nurse give to help prevent future stones?

A 52-year-old client presents to the clinic with complaints of fatigue, weight gain, and feeling cold even in warm environments. The client also reports having dry skin. The healthcare provider suspects hypothyroidism. Which assessment finding should the nurse anticipate in this client?

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which intervention should the nurse implement to promote adequate gas exchange?

The nurse is caring for a client recently diagnosed with hypothyroidism. Which nursing intervention is most appropriate to include in the plan of care?