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. Avoiding tight-fitting clothes can help reduce intra-abdominal pressure, which may contribute to GERD symptoms, but it is not the most crucial instruction.
B. Minimizing intake of spicy foods can help decrease gastric irritation and reflux symptoms, but it is not the most important instruction.
C. Beginning a smoking cessation program is important for overall health and may help reduce GERD symptoms, but it is not the most critical instruction for managing GERD.
D. Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter. This instruction helps minimize reflux episodes and should be emphasized to the client with GERD.
Correct Answer is A
Explanation
A. Crohn's disease with colectomy. Peritoneal dialysis involves instilling dialysis fluid into the peritoneal cavity, and conditions that affect the integrity or function of the peritoneum, such as Crohn's disease with colectomy, can be contraindications due to the risk of infection or inadequate dialysis.
B. Latent hepatitis C is not a contraindication for peritoneal dialysis, although active hepatitis C infection may be a concern due to increased risk of peritonitis.
C. Type 2 diabetes mellitus is not a contraindication for peritoneal dialysis; in fact, it is a common cause of end-stage renal disease and may necessitate dialysis.
D. Nephrotic syndrome history is not a contraindication for peritoneal dialysis; in fact, peritoneal dialysis may be indicated in some cases of renal failure associated with nephrotic syndrome.
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