After a change-of-shift report, which patient should the nurse assess first?
A patient with kidney stones who has not voided for 12 hours.
A patient with kidney stones who has blood in the urine.
A patient with a urinary tract infection (UTI) who has a fever of 100 degrees (37.7 Celsius).
A patient with a UTI who has cloudy urine.
The Correct Answer is A
Choice A rationale
Twelve hours without voiding indicates potential acute urinary retention due to ureteral obstruction, risking hydronephrosis or kidney damage, which requires immediate attention to preserve renal function.
Choice B rationale
Hematuria is common with kidney stones and generally not urgent unless accompanied by clots causing retention or excessive bleeding causing hemodynamic instability.
Choice C rationale
Fever indicates infection but at 37.7°C, it is considered low-grade and less urgent compared to obstruction. Normal body temperature is typically 36.1-37.2°C.
Choice D rationale
Cloudy urine suggests infection but lacks the immediacy of urinary retention or acute obstruction, which are potentially life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
X-rays are commonly used to diagnose osteoarthritis as they effectively visualize joint space narrowing, osteophyte formation, and subchondral sclerosis, which are characteristic of OA. These imaging findings assist in confirming the diagnosis and assessing disease progression.
Choice B rationale
Lithography is not a diagnostic tool used for OA. It primarily refers to a printing method and has no relevance to imaging joints affected by osteoarthritis or diagnosing the condition scientifically.
Choice C rationale
Ultrasound can visualize soft tissues but is not routinely used for OA diagnosis. It does not provide the detailed assessment of joint degeneration seen in X-rays, making it less appropriate for identifying OA-related changes.
Choice D rationale
Echocardiograms are used to assess heart function and have no application in diagnosing osteoarthritis. They are irrelevant in imaging joint structures or evaluating degenerative joint diseases scientifically. .
Correct Answer is C
Explanation
Choice A rationale
Administering 1 mg of glucagon intramuscularly is unnecessary for a patient who is awake, alert, and able to swallow. Glucagon is reserved for patients who are unconscious and unable to swallow effectively to prevent choking.
Choice B rationale
Administering 25 g of dextrose IVP is unnecessary in this case because the patient is alert and able to swallow. Oral intake of carbohydrates is the preferred and safer intervention for mild hypoglycemia like 69 mg/dL.
Choice C rationale
Holding the insulin and encouraging the patient to eat provides glucose through dietary means, which is appropriate in a patient who is awake, alert, and hungry. A level of 69 mg/dL, though below normal, can be managed with oral glucose intake safely.
Choice D rationale
Calling the MD is not the immediate priority in managing mild hypoglycemia. Intervening directly to correct the glucose level with oral intake is more appropriate and effective in this situation.
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