A client with a renal calculus reports severe right flank pain, nausea, and vomiting.
Which nursing problem has the highest priority?

Acute pain related to renal calculus.

Nutritional deficit related to nausea.

Impaired renal function related to pain.

Risk for aspiration related to vomiting.

Answer and Explanation

The Correct Answer is D

A. Acute pain related to renal calculus is important and needs to be addressed, but managing potential life-threatening conditions, like aspiration, takes precedence.

B. Nutritional deficit related to nausea is also a concern but is not as urgent as preventing aspiration.

C. Impaired renal function related to pain could be important in the long term, but it does not pose an immediate risk like aspiration does. Therefore, it is not the highest priority.

D. Risk for aspiration related to vomiting is the highest priority because it addresses the immediate potential for airway compromise, which can be life-threatening if the client aspirates vomitus. Ensuring the airway is protected and that aspiration does not occur is critical.

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Correct Answer is ["B","E"]

Explanation

A. Serum potassium within the reference range is not typically a cause for concern in this scenario.

B. A hemoglobin A1C level of 7% indicates poor glycemic control and may suggest the need for adjustment in diabetes management, as it exceeds the recommended target range.

C. Total cholesterol within the reference range is not the most significant finding to report in this scenario.

D. Hematocrit within the reference range is not the most significant finding to report in this scenario.

E. A random plasma glucose level of 200 mg/dl (11.1 mmol/L) is indicative of hyperglycemia and requires attention as it suggests poor glycemic control, potentially related to diabetes.

A. Heart Rate 105 beats/minute B. Client can now speak in full sentences without pausing. C. Lung sounds clear D. Respirations 16 breaths/minute E. Client reports, “It’s a lot easier to breathe now.” F. Blood Pressure 122/84 mmHg

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Correct Answers:

Indicates the Interventions Were Successful: A, B, C, D, E, F

No Indication that the Interventions Were Successful: None

Rationale:

The assessment data provided indicates a positive response to the interventions for the asthma attack. The decrease in heart rate from 112 to 105 beats per minute, alongside the client's ability to speak in full sentences without pausing, suggests an improvement in respiratory function. Clear lung sounds and a reduction in respiratory rate to 16 breaths per minute further support this conclusion. The client's subjective report of eased breathing and the maintenance of blood pressure within normal limits post-intervention are also indicative of successful treatment. These observations collectively demonstrate the effectiveness of the administered medications and oxygen therapy in managing the acute asthma symptoms presented by the client.

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A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","E"]

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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A client with a renal calculus reports severe right flank pain, nausea, and vomiting.
Which nursing problem has the highest priority?