A client is admitted to the emergency room with renal colic due to renal lithiasis (stones). What is the nurse's highest priority in managing care for this client?
Prepare the client for lithotripsy to break up the stones.
Order a renal ultrasound to assess for the presence and location of the stones.
Administer pain medication as prescribed.
Initiate intravenous (IV) fluid therapy.
The Correct Answer is C
Choice A rationale
Preparing the client for lithotripsy is important for treatment but is not the immediate highest priority in an emergency setting. Immediate pain management takes precedence.
Choice B rationale
Ordering a renal ultrasound is necessary for assessing the stones but comes after stabilizing the client's acute symptoms, including managing pain.
Choice C rationale
Administering pain medication as prescribed is the highest priority because renal colic causes severe pain. Immediate pain relief is crucial for the client's comfort and to facilitate further diagnostic and therapeutic interventions.
Choice D rationale
Initiating IV fluid therapy is important for hydration and possibly aiding stone passage but follows after addressing the acute pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Preparing the client for lithotripsy is important for treatment but is not the immediate highest priority in an emergency setting. Immediate pain management takes precedence.
Choice B rationale
Ordering a renal ultrasound is necessary for assessing the stones but comes after stabilizing the client's acute symptoms, including managing pain.
Choice C rationale
Administering pain medication as prescribed is the highest priority because renal colic causes severe pain. Immediate pain relief is crucial for the client's comfort and to facilitate further diagnostic and therapeutic interventions.
Choice D rationale
Initiating IV fluid therapy is important for hydration and possibly aiding stone passage but follows after addressing the acute pain.
Correct Answer is D
Explanation
Choice A rationale
Stress and anxiety can contribute to gastrointestinal issues, but they are not the most likely cause of a duodenal ulcer.
Choice B rationale
Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause gastrointestinal irritation and ulcers, but Helicobacter pylori infection is a more common cause.
Choice C rationale
Excessive alcohol consumption can irritate the stomach lining and contribute to ulcer formation, but Helicobacter pylori infection is more likely to be the primary cause.
Choice D rationale
Helicobacter pylori infection is the most common cause of duodenal ulcers. The bacteria damage the protective lining of the stomach and duodenum, leading to ulcer formation. .
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