A nurse is caring for a client with a urological obstruction. What is the nurse's priority in this situation?

Prepare the client for surgery

Provide emotional support to the client

Assess vital signs and urine output

Administer patient's medication

Answer and Explanation

The Correct Answer is C

Choice a reason: Preparing the client for surgery may be necessary if the urological obstruction requires surgical intervention. However, it is not the immediate priority. Before considering surgical preparation, the nurse must assess the client's current condition to determine the severity of the obstruction and its impact on vital signs and urine output.
Choice b reason: Providing emotional support to the client is important for overall care, but it is not the nurse's immediate priority in the case of a urological obstruction. Emotional support should be provided once the client's physical condition has been stabilized and assessed.
Choice c reason: Assessing vital signs and urine output is the nurse's priority in managing a client with a urological obstruction. Monitoring these parameters helps the nurse evaluate the severity of the obstruction, detect any signs of complications such as infection or renal failure, and guide further interventions. Immediate assessment ensures timely and appropriate management of the client's condition.
Choice d reason: Administering medication may be part of the client's treatment plan, but it is not the priority action. Medication administration should follow the assessment of the client's vital signs and urine output to ensure that the chosen interventions are appropriate for the client's current status. Prioritizing assessment allows for more targeted and effective treatment.

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Correct Answer is C

Explanation

Choice A reason: Bed rest is not recommended for clients with urolithiasis because movement can help the passage of stones. Encouraging ambulation can aid in moving the stone and may help it pass more quickly.
Choice B reason: A high protein diet is not typically recommended for clients with urolithiasis. Excessive protein intake can increase the risk of kidney stone formation, particularly in those susceptible to uric acid stones.
Choice C reason: Encouraging the client to drink 3 liters of fluids per day is essential for clients with urolithiasis. Increased fluid intake helps dilute the urine and promotes the passage of the stone. It also helps in preventing the formation of new stones.
Choice D reason: A decrease in urine output is not expected and can indicate a complication such as obstruction. The goal is to maintain or increase urine output to help flush out the stone and prevent complications.

A. Start the flow of urine before passing the container under the stream to collect the specimen B. Remove the specimen container before stopping the stream of urine C. Use the provided towelette to cleanse the area by moving in a back-and-forth motion D. It will be easier to use your non-dominant hand to spread the labia

Correct Answer is C

Explanation

Choice a reason: Starting the flow of urine before passing the container under the stream to collect the specimen is an appropriate instruction. This technique is recommended to ensure that the initial part of the urine, which may contain contaminants from the urethral opening, is not collected. By allowing the first part of the urine to flow into the toilet, the midstream portion is considered cleaner and more representative for diagnostic testing.
Choice b reason: Removing the specimen container before stopping the stream of urine is also an appropriate instruction. This helps to ensure that only the midstream portion of the urine is collected, minimizing the risk of contamination from the skin or other surfaces. It also prevents the urine from splashing or overflowing, which could potentially contaminate the sample or the surrounding area.
Choice c reason: Using the provided towelette to cleanse the area by moving in a back-and-forth motion is incorrect and requires intervention. The proper technique for cleansing the area involves using the towelette to wipe from front to back in a single, continuous motion. This helps to reduce the risk of introducing bacteria from the perineal area into the urinary tract, which can lead to inaccurate test results or urinary tract infections.
Choice d reason: Instructing the client to use their non-dominant hand to spread the labia is an appropriate instruction. This technique helps to ensure that the urinary meatus is exposed and that the urine flows directly into the specimen container. Using the non-dominant hand allows the dominant hand to be used for holding and positioning the specimen container, making the process more manageable and reducing the risk of contamination.

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A nurse is caring for a client with a urological obstruction. What is the nurse's priority in this situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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