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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. always has a religious connotation: This statement is incorrect. While spirituality can be intertwined with religion for many individuals, it does not always have a religious connotation. Spirituality encompasses a broader sense of connection to something greater than oneself, which may or may not be associated with organized religion.
B. is a narrower concept than religion: This statement is incorrect. Spirituality is often considered a broader concept than religion. While religion typically involves organized beliefs, rituals, and practices within a specific faith tradition, spirituality encompasses a wider range of experiences, beliefs, and practices that relate to the search for meaning, purpose, and connection to the transcendent.
C. does not necessarily include religion: This statement is correct. Spirituality can exist independently of religion. While religion often involves spirituality, spirituality can encompass a wide range of beliefs, experiences, and practices that may or may not be connected to organized religion. Individuals can experience spirituality through various means such as nature, relationships, art, meditation, and personal reflection, regardless of religious affiliation.
D. has been created by humans to define ethical conduct: This statement is incorrect. Spirituality is not solely created by humans to define ethical conduct. While ethical principles and values may be part of spiritual beliefs for many individuals, spirituality encompasses broader aspects of human experience, including the search for meaning, connection, and transcendence, which extend beyond ethical conduct.
Correct Answer is A
Explanation
A. Be available to the client: This is the most appropriate action for the nurse to take. The client's question reflects existential distress and a search for meaning in the face of suffering. Being available to listen to the client's concerns, offering emotional support, and providing a safe space for the client to express their feelings can be comforting and therapeutic. The nurse should demonstrate empathy, validate the client's emotions, and encourage open communication without imposing personal beliefs or judgments.
B. Call the physician for an antianxiety medication: While the client may be experiencing anxiety or distress, immediately resorting to medication is not the most appropriate response to the client's existential question. Antianxiety medication may provide temporary relief of symptoms but does not address the underlying spiritual or existential distress. It is essential for the nurse to explore the client's concerns and provide holistic support rather than solely relying on pharmacological interventions.
C. Advise the client to pray for answers: This response imposes the nurse's religious or spiritual beliefs onto the client and may not be appropriate for individuals who do not share the same beliefs. It is essential for the nurse to respect the client's autonomy and beliefs while providing support and guidance. Instead of advising the client to pray, the nurse should focus on active listening, empathy, and providing nonjudgmental support.
D. Share personal religious beliefs with the client: Sharing personal religious beliefs with the client is not appropriate in this situation. Doing so may impose the nurse's beliefs onto the client, which can be perceived as intrusive or insensitive. It is essential for the nurse to maintain professional boundaries and respect the client's autonomy, beliefs, and preferences. The focus should be on providing empathetic support and addressing the client's emotional and existential concerns.
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