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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale
Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.
Choice A rationale
Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.
Choice B rationale
Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.
Choice D rationale
Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.
Correct Answer is A
Explanation
Choice A rationale
A terminal ileostomy involves creating an opening in the right lower quadrant of the abdomen where the ileum is brought to the surface to form a stoma for waste elimination.
Choice B rationale
The left lower quadrant is not used for a terminal ileostomy, as it is not anatomically appropriate for the ileum.
Choice C rationale
The right upper quadrant is not relevant to a terminal ileostomy because the ileum is located in the lower part of the abdomen.
Choice D rationale
The left upper quadrant is also inappropriate for a terminal ileostomy due to the anatomical position of the ileum. .
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