A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
Palpate the right flank for tenderness.
Evaluate the urine for a strong odor.
Test the urine for the presence of hematuria.
Measure the temperature and pulse rate.
The Correct Answer is D
D. In a client presenting with urinary symptoms and lower back pain, measuring the temperature and pulse rate is essential for assessing for signs of systemic infection, such as fever (elevated temperature) and tachycardia (elevated pulse rate). These vital signs can help determine the urgency of the situation and guide further assessment and management.
A. Palpating the right flank for tenderness may be appropriate to assess for signs of kidney involvement, such as in pyelonephritis. However, this intervention is not the first priority. Assessing for systemic signs of infection, such as fever, is more urgent.
B. Evaluating the urine for a strong odor may provide additional information about the student's symptoms, but it is not the first intervention priority.
C. Testing the urine for the presence of hematuria (blood in the urine) is an important diagnostic step in evaluating urinary symptoms, but it is not the first intervention priority. Hematuria may be present in various conditions, including UTIs, kidney stones, or other urinary tract disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Dietary intake plays a significant role in the management of chronic pancreatitis pain. Certain foods, especially those high in fat, can exacerbate symptoms and trigger pain episodes in clients with pancreatitis.
A. While assessing the activity level of bowel sounds is important for monitoring gastrointestinal function, it is not the most crucial assessment data in this scenario. Bowel sounds may be decreased or absent in clients with severe abdominal pain, but addressing the dietary triggers of chronic pancreatitis pain takes priority.
C. Assessing the level and amount of physical activity is important for overall health and may play a role in managing chronic pancreatitis. However, in the context of persistent gnawing abdominal pain, addressing dietary factors that exacerbate the pain is more immediate and crucial.
D. Assessing the color and consistency of feces is important for monitoring gastrointestinal function and identifying signs of malabsorption or steatorrhea, which can occur in chronic pancreatitis. However, in the context of persistent gnawing abdominal pain, assessing dietary intake and potential triggers of pain is more pertinent to pain management.
Correct Answer is A
Explanation
A. The client is receiving heparin sodium, an anticoagulant medication, which increases the risk of bleeding during surgery, especially in combination with the open fracture and ongoing bleeding. The healthcare provider needs to be informed of the client's medication history to determine the appropriate management of anticoagulation therapy perioperatively.
B. While obtaining informed consent for surgery and potential blood transfusion is important, it is not the priority in this situation.
C. Monitoring the injection sites for signs of bruising is important for assessing for complications related to heparin administration, such as hematoma formation or bleeding. However, in the context of a client with an open fracture and moderate bleeding, the priority is to address the potential interaction between heparin therapy and the risk of bleeding from the fracture site.
D. While it is important to provide education to the client about the potential risks and complications associated with surgery, including bleeding, this is not the priority nursing action in this situation.
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.