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.
Test the urine for the presence of hematuria.
Evaluate the urine for a strong odor.
Measure the temperature and pulse rate.
The Correct Answer is D
A. Palpating the right flank for tenderness is essential to assess for possible renal involvement, such as a kidney infection or kidney stone, which could be causing the urinary symptoms and right lower back pain. However, it is not the initial step.
B. Testing the urine for the presence of hematuria is important in assessing for potential urinary tract infection or other renal pathology but does not directly address the cause of the right lower back pain.
C. Evaluating the urine for a strong odor may provide information about a possible urinary tract infection, but it is not the most immediate intervention for addressing the client's symptoms, compared to measuring the vital signs.
D. Measuring the temperature and pulse rate is important for identifying any signs of systemic infection or inflammation that could be contributing to the patient's symptoms.
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Related Questions
Correct Answer is B
Explanation
A. Collecting the blood sample from a reddened and engorged fingertip may lead to inaccurate glucose readings and can cause discomfort to the client. Selecting another finger is a more appropriate action.
B. Selecting another finger ensures an accurate blood sample and minimizes discomfort to the client. It allows for a fresh puncture site that is not engorged, improving the accuracy of the glucose reading.
C. Applying pressure to the site may temporarily reduce engorgement but may not be sufficient to obtain an accurate blood sample. Selecting another finger is a more appropriate action.
D. Assessing radial pulse volume is not necessary in this situation, as the client's fingertip appearance does not indicate compromise of peripheral circulation.
Correct Answer is B
Explanation
A. Alternating IV and IM analgesic medications may be appropriate for pain management in some situations but is not the best initial intervention for continuous, severe pain in a client with stage IV bone cancer.
B. Administering opioid and non-opioid medication simultaneously is an appropriate intervention for managing severe pain, as it addresses pain from multiple pathways and may provide more effective pain relief.
C. Giving maximum dosage when the pain score reaches 10 is not recommended, as it may lead to overmedication and increased risk of adverse effects. Pain management should be based on the client's reported pain intensity and individualized needs.
D. Educating the client on signs and symptoms of narcotic dependency is important but is not the priority intervention in this situation. Pain management and relief should be the immediate focus for the client's comfort and quality of life.
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