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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Fractures caused by disease processes are termed pathological fractures. Diseases like osteoporosis weaken bones, increasing susceptibility to fractures. Conditions like cancer can invade bone tissue, causing structural fragility. Pathological fractures occur without significant trauma, distinguishing them from those caused by external injuries, which require high-impact forces to break otherwise healthy bones. By definition, trauma fractures arise from external forces, while pathological ones involve internal conditions compromising bone integrity.
Choice B rationale
Traumatic fractures stem from external forces, not from disease processes. This assertion neglects the reality of pathological fractures, which result from diseases undermining the bone's natural strength. Healthy bones typically endure significant stress before fracturing, and the absence of disease makes fractures from minimal trauma highly unlikely. This reasoning excludes pathological fractures caused by internal illnesses or conditions weakening bone structures.
Correct Answer is A
Explanation
Choice A rationale
Loss of sensation to the perineum, buttocks, inner thighs, and back of the legs may indicate cauda equina syndrome, a surgical emergency. This condition involves compression of the spinal nerve roots and can lead to permanent neurological damage if not promptly addressed. Immediate medical intervention is critical.
Choice B rationale
Nausea and delayed voiding postoperatively are common, potentially due to anesthesia effects or limited mobility. While these findings warrant monitoring, they do not typically indicate an urgent issue unless prolonged or associated with other complications.
Choice C rationale
Mild low back pain is expected after lumbar spinal surgery due to manipulation of spinal structures. Pain management with prescribed analgesics and gradual mobilization is part of the standard postoperative care plan, and it does not usually necessitate immediate reporting.
Choice D rationale
A single episode of emesis can result from anesthesia effects or medication. Unless accompanied by persistent vomiting, signs of aspiration, or electrolyte imbalances, isolated emesis is not typically urgent and should be managed with antiemetics if necessary.
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