A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
Evaluate the urine for a strong odor.
Measure her temperature and pulse rate
Test her urine for the presence of hematuria.
Palpate the right flank for tenderness
The Correct Answer is B
A. Evaluate the urine for a strong odor.
While evaluating urine for a strong odor can provide some information about a possible urinary tract infection (UTI), it is not the most immediate concern. The priority in this case is to assess for signs of systemic infection, and checking for a strong odor can be done later.
B. Measure her temperature and pulse rate.
This is the correct choice. Measuring temperature and pulse rate is a critical initial step to assess for signs of systemic infection. Fever and an elevated pulse rate can indicate that the infection may have spread beyond the bladder, possibly involving the kidneys.
C. Test her urine for the presence of hematuria.
Testing for hematuria (blood in the urine) is an important diagnostic step for a UTI, but it is not the first priority. Vital sign assessment takes precedence to determine the severity of the condition and the need for urgent intervention.
D. Palpate the right flank for tenderness.
Palpating the right flank for tenderness is a relevant physical assessment to check for kidney involvement, which is important in cases of suspected pyelonephritis. However, assessing vital signs is a more immediate and critical step to determine the severity of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Irrigating the catheter manually:
Manually irrigating the catheter without an order may disrupt the clotting process and increase the risk of bleeding. It is not a routine nursing intervention post-TURP without specific orders.
B. Monitoring catheter drainage.
It is not within the nurse's scope of practice to manually irrigate the catheter without a healthcare provider's order, especially in the context of post-TURP care. The dark, pink-tinged outflow with blood clots indicates some expected bleeding following the procedure. The nurse should closely monitor the catheter drainage for the amount, color, and presence of clots.
C. Discontinuing infusing solution:
Discontinuing the normal saline irrigation may lead to clot formation and obstruction, potentially worsening the situation. The continuous bladder irrigation is often used to prevent clot formation and maintain catheter patency post-TURP.
D. Decreasing the flow rate:
The flow rate is typically set by the healthcare provider to maintain catheter patency and prevent clot formation. Decreasing the flow rate without specific orders may not be appropriate in this situation.
Correct Answer is ["B","D"]
Explanation
A. Use standard precautions and wear a mask:
The use of standard precautions is appropriate for general care to prevent the transmission of infectious agents. However, specific to MRSA, additional precautions are needed. Wearing a mask is generally not necessary unless the client has respiratory symptoms that warrant respiratory precautions.
B. Institute contact precautions for staff and visitors:
This is a correct intervention. Contact precautions involve using gowns and gloves when providing care to prevent the transmission of MRSA. It is important for both healthcare staff and visitors to adhere to contact precautions to reduce the risk of spreading the infection.
C. Explain the purpose of a low bacteria diet:
The purpose of a low bacteria diet is generally unrelated to the management of MRSA. Low bacteria diets are often recommended for individuals with compromised immune systems to reduce the risk of foodborne infections. However, it may not be directly applicable to MRSA management.
D. Monitor the client's white blood cell count:
Monitoring the white blood cell count is a relevant intervention. An elevated white blood cell count may indicate an ongoing infection or an inflammatory response. Regular monitoring helps assess the client's immune response and the potential severity of the infection.
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