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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.
B. The activity level of bowel sounds may provide information about gastrointestinal motility but is not directly related to pain management in chronic pancreatitis.
C. Physical activity can impact overall health but may not directly alleviate abdominal pain associated with chronic pancreatitis.
D. The color and consistency of feces may indicate malabsorption or other gastrointestinal issues but may not directly address the client's pain management needs.
Correct Answer is ["A","B","C","D","F"]
Explanation
A. The patient’s oxygen saturation remains below the target of 94% despite initial oxygen therapy. Therefore, increasing the oxygen flow might be necessary to achieve better oxygenation.
B. Since the patient remains symptomatic with ongoing wheezes, administering another dose of the nebulizer treatment as ordered, since the prescription included PRN can help to further open the airways and alleviate wheezing.
C. Elevating the head of the bed can help improve lung expansion and ease the work of breathing, which is particularly beneficial in respiratory distress situations.
D. Switching to a nonrebreather mask may be appropriate if the patient’s oxygen saturation does not improve sufficiently with the current method of oxygen delivery. This type of mask can deliver a higher concentration of oxygen.
E. While incentive spirometry is generally used for preventing pulmonary complications (such as pneumonia or atelectasis) after surgery or in conditions where patients are likely to be immobile, it may not be immediately beneficial or a priority in the acute management of an asthma attack. The primary focus should be on stabilizing the patient’s respiratory status through medication and oxygen therapy. Thus, this option is less critical at this stage.
F. Continuous monitoring of vital signs is crucial in acute cases like this to assess the patient's response to interventions and detect any deterioration in the clinical status.
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