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 B
Explanation
Choice A rationale
Endoscopy is a diagnostic procedure used for evaluating persistent or severe symptoms of heartburn, but it is not part of initial treatment. Patient education focuses on symptom relief and management strategies before invasive testing.
Choice B rationale
Proton pump inhibitors reduce gastric acid secretion by irreversibly blocking H+/K+ ATPase in stomach parietal cells. They are first-line medications for heartburn and gastroesophageal reflux disease, effectively relieving symptoms and preventing complications.
Choice C rationale
Radionuclide tests are specialized diagnostic procedures for conditions such as gastric emptying disorders. They are not standard educational topics for new heartburn complaints, as they do not provide immediate symptom relief.
Choice D rationale
A barium swallow is used for imaging structural abnormalities of the esophagus or stomach but is not part of initial management for heartburn. It is a diagnostic tool rather than a first-line treatment or educational focus. .
Correct Answer is C
Explanation
Choice A rationale
Checking blood pressure does not directly address the faint pulses and cool foot. While hypotension could contribute to peripheral perfusion issues, the signs described more likely indicate compartment syndrome, which requires urgent action.
Choice B rationale
Repositioning the leg might provide some comfort but does not alleviate the potential compartment syndrome. Elevation could worsen ischemia by reducing arterial blood flow.
Choice C rationale
Compartment syndrome is a medical emergency caused by increased pressure within a muscle compartment. This pressure compromises circulation and tissue viability. The nurse must notify the health care provider immediately to prevent permanent damage.
Choice D rationale
Assessing the incision for redness delays addressing the critical signs of potential compartment syndrome. Redness indicates infection, but faint pulses and a cool extremity necessitate more urgent evaluation.
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