An adult is admitted with acute flank pain, a 102°F (38.9°C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.

Obtain clean catch urine for culture and sensitivity.

Initiate broad spectrum IV antibiotic as secondary infusion.

Collect a serum sample for hemoglobin and hematocrit.

Give diphenhydramine prep for intravenous pyelogram.

Force oral fluids to 2,000 mL/24 hours.

Answer and Explanation

Correct Answer : A,B

Choice A reason: Obtaining a clean catch urine sample for culture and sensitivity is crucial for identifying the specific bacteria causing the infection and determining the appropriate antibiotic treatment.

Choice B reason: Initiating broad spectrum IV antibiotics is important to start treating the infection immediately, especially given the severity of the symptoms.

Choice C reason: Collecting a serum sample for hemoglobin and hematocrit is not immediately necessary in this scenario. The focus should be on diagnosing and treating the infection.

Choice D reason: Giving diphenhydramine prep for intravenous pyelogram is not relevant to the immediate management of the client's condition.

Choice E reason: Forcing oral fluids can help flush out the urinary system, but it is not the most critical initial intervention compared to obtaining a urine culture and starting antibiotics.

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Correct Answer is D

Explanation

Choice A reason: Researching the religion on social media is not a reliable or appropriate method for understanding individual care needs.

Choice B reason: Consulting with a nurse who shares the same religious beliefs may provide insight but does not address the specific concerns of the client.

Choice C reason: Explaining that every client receives the same high level of care does not address the client's individual religious needs and concerns.

Choice D reason: Asking the client about individual care preferences ensures that the nurse understands and respects the client's specific religious beliefs and practices.

A. Observe neck for jugular vein distention. B. Monitor oxygen saturation via continuous pulse oximetry. C. Notify healthcare provider to prepare for pericardiocentesis. D. Assess for paradoxical blood pressure.

Correct Answer is C

Explanation

Choice A reason: Observing for jugular vein distention is important but not the immediate intervention.

Choice B reason: Monitoring oxygen saturation is necessary but secondary to preparing for pericardiocentesis.

Choice C reason: Pericardiocentesis is the definitive treatment for cardiac tamponade, and notifying the healthcare provider to prepare for this procedure is the most important intervention.

Choice D reason: Assessing for paradoxical blood pressure helps confirm cardiac tamponade but does not address the immediate need for treatment.

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An adult is admitted with acute flank pain, a 102°F (38.9°C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

Correct Answer is D

Explanation

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

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