The nurse collects a urine sample from a newly admitted client. The color of the urine is slightly pink. The first nursing action would be to:

ask about medications the client currently takes.

check the client's vital signs.

notify the healthcare provider about the bleeding.

send the urine to the lab for culture and sensitivity.

Answer and Explanation

The Correct Answer is A

A. Ask about medications the client currently takes: The first nursing action should be to gather information about potential causes of the pink coloration of the urine. Certain medications, foods, and medical conditions can cause urine discoloration. Asking about the medications the client currently takes can help identify if the pink coloration is due to a medication side effect, such as certain antibiotics, laxatives, or antipsychotics, which can cause urine to appear pink or reddish.

B. Check the client's vital signs: While assessing the client's vital signs is important for obtaining baseline data and assessing the client's overall health status, it may not provide immediate insights into the cause of the pink urine. Vital signs are unlikely to reveal the underlying cause of urine discoloration.

C. Notify the healthcare provider about the bleeding: Notifying the healthcare provider about the presence of pink urine is important, but it should not be the first action taken without gathering more information. Before contacting the healthcare provider, the nurse should assess the client's medications, recent dietary intake, and medical history to identify potential causes of the urine discoloration.

D. Send the urine to the lab for culture and sensitivity: Sending the urine to the lab for culture and sensitivity is not the first action indicated in this scenario. While urine analysis may be warranted to further evaluate the pink urine, it should be done after assessing the client's medications and obtaining additional information to determine the likely cause of the urine discoloration.

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Correct Answer is B

Explanation

A. Use open-ended questions to find out about the sensation: While open-ended questions can help the nurse gather information about the nature and quality of the pain, they may not provide a precise measure of pain intensity. Open-ended questions are valuable for understanding the client's subjective experience of pain, but they may not be as effective as using a pain scale for quantifying pain intensity.

B. Offer the client a pain scale to quantify the current level of pain: This is the most appropriate action for assessing pain intensity. Pain scales, such as the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS), allow clients to indicate their pain intensity on a scale from 0 to 10 or by marking a point along a continuum. Pain scales provide a standardized method for quantifying pain intensity, which helps healthcare providers monitor changes in pain over time and assess the effectiveness of pain management interventions.

C. Question the client about the location of the pain: While identifying the location of pain is important for understanding its source and potential underlying causes, it does not directly assess pain intensity. Location is one aspect of pain assessment but does not provide a complete picture of pain intensity on its own.

D. Ask about what precipitates the pain: Understanding what precipitates or exacerbates pain is important for comprehensive pain assessment, but it focuses more on pain triggers rather than pain intensity. While this information can be valuable for developing a holistic pain management plan, it does not directly assess the current level of pain intensity.

A. Temperature B. BP and pulse in lying, then sitting and standing positions C. Pulse oximetry reading on room air D. Respiratory rate and depth

Correct Answer is B

Explanation

A. Temperature: While temperature assessment is important in evaluating a client's condition, it primarily indicates the presence of fever, which the client already reports. However, it does not provide direct information about the client's fluid status.

B. BP and pulse in lying, then sitting and standing positions: Assessing blood pressure (BP) and pulse in different positions (lying, sitting, and standing) helps evaluate orthostatic changes, which can indicate volume depletion or dehydration. A drop in BP and an increase in pulse rate upon standing suggest volume depletion and orthostatic hypotension, which are indicators of fluid loss.

C. Pulse oximetry reading on room air: Pulse oximetry measures the oxygen saturation of arterial blood and is primarily used to assess respiratory status and oxygenation. While it provides valuable information about oxygen levels, it does not directly assess fluid status.

D. Respiratory rate and depth: Respiratory rate and depth can be affected by various factors, including pain, fever, and respiratory conditions. While changes in respiratory rate and depth can indicate distress or respiratory compromise, they are not specific indicators of fluid status and may not directly reflect hydration status.

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The nurse collects a urine sample from a newly admitted client. The color of the urine is slightly pink. The first nursing action would be to:

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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