A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?
Apply cold compress to the client's flank area
Restrict protein intake to 2 servings per day.
Encourage intake of at least 3 L of fluids per day
Discourage ambulation
The Correct Answer is C
A. Apply cold compress to the client's flank area - Applying a warm compress, not a cold one, to the flank area can help alleviate pain associated with urolithiasis. Heat can promote muscle relaxation and increase blood flow to the area, potentially easing discomfort.
B. Restrict protein intake to 2 servings per day - There is no direct connection between protein intake and urolithiasis. However, specific dietary recommendations may vary based on the type of kidney stones a person has. For example, individuals with certain types of stones might be advised to limit oxalate-rich foods. It's essential to tailor dietary advice based on the composition of the stones.
C. Encourage intake of at least 3 L of fluids per day - Adequate fluid intake, particularly water, is crucial for preventing the formation of kidney stones. Increased fluid intake can help dilute substances in the urine that contribute to stone formation, reducing the risk of stone recurrence.
D. Discourage ambulation - Encouraging ambulation and movement is generally beneficial for patients with urolithiasis. Movement can help alleviate discomfort, prevent complications such as blood clots, and promote overall well-being. Restricting movement unnecessarily is not advisable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["25"]
Explanation
To calculate the number of hours required to infuse two 1L bags of normal saline at a rate of 80 ml/hr, you can use the following formula:
Time (hours) = Total volume (ml) / Infusion rate (ml/hr)
First, calculate the total volume of normal saline to be infused:
Total volume = 2 bags x 1L/bag x 1000 ml/L = 2000 ml
Now, plug this into the formula:
Time (hours) = 2000 ml / 80 ml/hr
Time (hours) = 25 hours
So, it will take 25 hours to infuse the total amount of normal saline at a rate of 80 ml/hr, assuming no interruptions in the infusion. Rounded to the nearest whole number, it will take 25 hours.
Correct Answer is C
Explanation
A. Hypovolemic shock: Hypovolemic shock occurs when there is a significant loss of blood or fluids in the body, leading to insufficient blood volume to maintain normal circulation. Symptoms include rapid heart rate, low blood pressure, confusion, and cold, clammy skin. While hypovolemic shock is a concern in trauma patients, the symptoms described by the client (shortness of breath and chest pain) are not typical of hypovolemic shock.
B. Fat embolism syndrome: Fat embolism syndrome occurs when fat particles are released into the bloodstream, often after a long bone fracture or trauma. These fat particles can block small blood vessels, leading to symptoms such as respiratory distress, confusion, and petechial rash (small red or purple spots under the skin). While fat embolism syndrome is a concern in patients with long bone fractures, the symptoms described by the client are more suggestive of a pulmonary embolism.
C. Venous thromboembolism (VTE): VTE refers to the formation of blood clots in the veins. Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein, usually in the legs, while pulmonary embolism (PE) occurs when a clot breaks loose and travels to the lungs. Symptoms of PE can include sudden chest pain, shortness of breath, rapid heart rate, and cough, which may produce bloody or blood-streaked sputum. Given the client's symptoms of shortness of breath and chest pain, VTE, specifically pulmonary embolism, is a significant concern.
D. Compartment syndrome: Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow and potential nerve damage. Symptoms can include severe pain, swelling, and numbness or tingling. While compartment syndrome is a complication of fractures, the symptoms described by the client (shortness of breath and chest pain) are not characteristic of compartment syndrome.
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