A client who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?
Insert a foley catheter.
Schedule a pelvic magnetic resonance imaging test.
Infuse normal saline at 50 ml/hr.
Draw blood for a complete blood count.
The Correct Answer is A
A. The primary concern in this scenario is urinary retention, which can lead to kidney dysfunction (indicated by elevated BUN and creatinine). The priority intervention is relieving the retention by inserting a Foley catheter, which will help restore normal urinary output and prevent further complications.
B. MRI is not an immediate priority when the client is at risk for kidney damage due to urinary retention.
C. While IV fluids may be necessary, the first priority is relieving the obstruction causing urinary retention.
D. Drawing blood is important for assessing the client's condition but is not as urgent as managing urinary retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.
B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.
C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.
D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.
Correct Answer is D
Explanation
A. Drinking water is not likely to alleviate the headache caused by the nitrate.
B. Holding the next dose is not necessary unless the headache becomes severe or is associated with other symptoms.
C. Initiating oxygen therapy is unnecessary for a headache caused by nitrate use.
D. A headache is a common side effect of nitrate administration due to the vasodilation effect. Administering PRN acetaminophen can help relieve the headache.
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