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?

C. Risk for aspiration related to vomiting.Nausea and vomiting increase the risk of aspiration because the vomitus can enter the airway if the client is unable to protect their airway effectively. Therefore, it is critical for the nurse to prioritize interventions aimed at reducing the risk of aspiration, such as maintaining the client in a side-lying position and providing suctioning equipment as needed.
A. While renal function impairment is a potential complication of kidney stones, it is not the most immediate concern in this scenario. The client's severe right flank pain, nausea, and vomiting indicate an acute episode of renal colic, where the kidney stone obstructs the urinary tract, causing intense pain and urinary stasis. While impaired renal function is a concern, it is secondary to the immediate risk of aspiration.
B. Acute pain related to the renal calculus is a significant concern for the client and requires prompt intervention to alleviate discomfort. However, in this scenario, the risk of aspiration from vomiting takes precedence over pain management because aspiration poses an immediate threat to the client's respiratory status.
D. While nutritional deficit related to nausea is a valid concern, it is not the highest priority nursing problem in this scenario. The client's nausea and vomiting are acute symptoms requiring immediate attention to prevent complications such as aspiration. Once the risk of aspiration is addressed, nutritional support and interventions to manage nausea can be implemented.

D. Pins or wires are often inserted into the bone to apply traction, and these insertion sites provide a potential route for infection. The nurse should assess the pin sites regularly for signs of infection, such as redness, swelling, warmth, or drainage. Early detection and treatment of pin site infections help prevent the spread of infection and promote healing.
A. Administer pain medication at designated intervals around the clock:
While pain management is important for a client with a fracture, the primary intervention for skeletal traction is not necessarily related to pain medication administration.
B. Assessing pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this intervention is more relevant to vascular assessment and may not be directly related to skeletal traction.
C. Skeletal traction is typically maintained continuously to provide consistent traction and promote proper alignment of the fractured bone. Removing traction every shift would disrupt the therapeutic effect and delay healing.