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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is ["125"]
Explanation
Correct Answer: 125 mL/hr
Rationale:
To calculate the infusion rate in mL/hr, you can use the formula: (Total Volume in mL) / (Time in hours) = Rate in mL/hr. For 1 liter (which is 1000 mL) of lactated Ringers to be infused over 8 hours, the calculation would be 1000 mL / 8 hr = 125 mL/hr.
Therefore, the nurse should program the infusion pump to deliver 125 mL of fluid per hour.
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