A 72-year-old client is admitted to the medical-surgical unit with a diagnosis of acute pyelonephritis. The client complains of costovertebral tenderness. What it the most appropriate nursing intervention?

Notify the physician since this is a sign of deterioration.

Offer the client back massage to reduce the pain.

Place the client in prone position to limit vesicoureteral reflux.

Offer the client an analgesic if prescribed.

Answer and Explanation

The Correct Answer is D

A.   While costovertebral tenderness is significant and indicates kidney involvement, it is a common symptom of acute pyelonephritis and not necessarily a sign of deterioration. Immediate notification may not be warranted unless other concerning symptoms are present.
B.   Although back massage may seem comforting, it is not indicated in this scenario. The kidneys are inflamed, and massage could exacerbate pain or discomfort. It does not address the underlying condition or the pain effectively.
C.   The prone position is not typically recommended for clients with pyelonephritis. Instead, the client may be more comfortable in a position that does not put pressure on the kidneys, such as sitting up or lying on their back or side. This intervention does not directly address the pain or comfort of the client.
D.   Offering an analgesic is the most appropriate action. Pain management is crucial for the comfort of the client, and an analgesic can help alleviate the discomfort associated with costovertebral tenderness. If the physician has prescribed an analgesic, administering it would be in line with promoting comfort and addressing the client’s needs.

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Correct Answer is C

Explanation

A. While skipping meals can affect blood glucose levels, it is not a direct primary cause of DKA. In some cases, if a person with Type 1 diabetes skips a meal and does not adjust their insulin accordingly, it could lead to hyperglycemia. However, the absence of insulin is the critical factor in DKA.
B. Gastrointestinal disturbances, such as vomiting or diarrhea, can contribute to DKA by leading to dehydration and altering insulin absorption. However, they are not primary causes. The main concern is that they may cause the individual to skip insulin or not manage their diabetes effectively.
C. DKA is primarily caused by a lack of insulin, which leads to the body breaking down fat for energy instead of glucose. This process produces ketones, which can accumulate and lead to acidosis. For individuals with Type 1 diabetes, consistently taking insulin is crucial to prevent DKA.
D. An insulin overdose can lead to hypoglycemia, not DKA. When too much insulin is taken, it can cause blood glucose levels to drop too low, which is the opposite of what occurs in DKA.

A. makes the blood less thick and easier to flow." B. does not thin the blood: it prevents new clots from forming." C. decreases the number of platelets so the blood clots more slowly." D. dissolves the clot and decreases the formation of platelets."

Correct Answer is B

Explanation

A. Heparin does not actually "thin" the blood in the sense of reducing viscosity. Instead, it works by inhibiting certain factors in the coagulation cascade, preventing clot formation. Thus, this response does not accurately describe how heparin functions.

B. Heparin works by activating antithrombin III, which inhibits thrombin and factor Xa, thereby preventing the formation of new clots. It does not dissolve existing clots but helps to prevent the enlargement of existing ones and the formation of new clots.
C. Heparin does not decrease the number of platelets; rather, it interferes with the clotting process by inhibiting specific clotting factors. Platelets may still be present, but their ability to form clots is inhibited by the action of heparin.
D. Heparin does not dissolve existing clots; that function is typically performed by thrombolytic agents. Heparin primarily prevents new clot formation and the extension of existing clots. Additionally, it does not decrease platelet formation.

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A 72-year-old client is admitted to the medical-surgical unit with a diagnosis of acute pyelonephritis. The client complains of costovertebral tenderness. What it the most appropriate nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching an adult client with Type 1 diabetes that a primary cause of the development of diabetic ketoacidosis (DKA) is:

Correct Answer is C

Explanation

The client diagnosed with deep vein thrombosis asks the nurse, "How does heparin work to help with my blood clot?" Which response is most accurate? "Heparin:

Correct Answer is B

Explanation

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