A client with renal calculi is experiencing hematuria and reports severe flank pain.
Which intervention should the nurse implement first?
Obtain a urine specimen for analysis.
Administer a prescribed opioid analgesic.
Strain the urine for the presence of stones.
Prepare the client for a prescribed computed tomography (CT) scan.
Prepare the client for a prescribed computed tomography (CT) scan.
The Correct Answer is B
Choice A rationale:
Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.
Choice B rationale:
This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.
Choice C rationale:
Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.
Choice D rationale:
Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Emphasize that using safe sex practices removes the risk of STIs. Rationale: While promoting safe sex practices is essential in preventing STIs, this response is not directly addressing the client's situation. The client already reports having unprotected sex, so this choice does not provide relevant information or address the potential consequences.
Choice B rationale:
Explain that reinfections occur from sex with untreated partners. Rationale: This is the correct response. Syphilis is a sexually transmitted infection that can be treated with antibiotics, but reinfections can occur if sexual partners are not treated. This response provides essential information about the potential consequences of unprotected sex with untreated partners.
Choice C rationale:
Clarify that all STIs are transmitted through sexual intercourse. Rationale: While this statement is accurate in a general sense, it does not specifically address the client's situation or the risks associated with syphilis. It lacks the focus needed to educate the client effectively about their current situation.
Choice D rationale:
Provide counseling that most contraceptives protect against infection. Rationale: This response is inaccurate. Contraceptives primarily aim to prevent pregnancy, not protect against STIs. Therefore, it does not address the client's concern or provide relevant information about syphilis.
Correct Answer is A
Explanation
Choice A rationale: The spasm described is Trousseau's sign, a classic indicator of hypocalcemia. Inflating a blood pressure cuff above systolic pressure causes carpal spasm due to increased neuromuscular irritability, requiring immediate assessment of serum calcium levels.
Choice B rationale: Carpal spasms during blood pressure measurement are a physiological manifestation of electrolyte imbalance, not psychological distress. Administering antianxiety medication would delay necessary treatment for a potentially life-threatening calcium deficiency.
Choice C rationale: Moving the cuff to the other arm would likely produce the same result because hypocalcemia is a systemic condition. This action ignores the underlying physiological cause and fails to address the client's safety.
Choice D rationale: The spasms are a physical reaction from the client, not a malfunction of the equipment. Replacing the sphygmomanometer would be an ineffective intervention that misses the clinical significance of the sign.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.