The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Ask the client if he took any pain medication at home.

Observe for nonverbal signs to measure pain intensity.

Use a standard pain assessment questionnaire and scale.

Collect a urine sample and strain for granules or calculi.

Answer and Explanation

The Correct Answer is D

A.   While it’s important to assess whether the client has already taken pain medication, this should not be the first intervention. The priority is to assess the client's current status and gather information to guide the next steps in care.
B.   Observing nonverbal signs of pain can be helpful, but the first priority is to assess the cause of the pain and collect pertinent data to determine if it’s related to kidney stones or another condition. Nonverbal signs are secondary to clinical assessment.
C.   Using a pain scale would be appropriate after performing an initial assessment to determine the cause of the pain. While this helps gauge pain intensity, it is not the most urgent action in the case of suspected kidney stones.
D.   The first priority in a client with flank pain and a history of kidney stones is to collect a urine sample and strain it for calculi.

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Correct Answer is D

Explanation

A. Tympany indicates the presence of gas within the intestines. This would not be expected over the liver area if there is hepatomegaly.
B. This is not an expected finding in hepatomegaly. Tympany is associated with air-filled structures, which would not be present over an enlarged liver.
C. A hollow sound is also indicative of air-filled organs like the intestines. It is not a sign of hepatomegaly, which would be characterized by dullness on percussion.
D. Dullness upon percussion outside the costal margins suggests an enlarged liver (hepatomegaly). This is due to the liver becoming larger and filling the space that normally contains air-filled organs like the intestines.

A. Absent deep tendon reflexes. B. Capillary refill less than 3 seconds. C. 3+ peripheral dependent edema. D. Oxygen saturation of 85%.

Correct Answer is D

Explanation

A. Absent deep tendon reflexes are not typically associated with nailbed clubbing. While reflexes may be diminished in some conditions, they are not commonly related to the pathophysiology behind clubbing.
B. A capillary refill time of less than 3 seconds is a normal finding and does not align with clubbing, which often indicates chronic hypoxia or systemic conditions such as heart or lung disease.
C. Peripheral dependent edema refers to swelling in the lower extremities, which can be associated with circulatory problems, but it is not directly linked to nailbed clubbing. Edema is more common in conditions like heart failure or kidney disease.
D. A low oxygen saturation of 85% is consistent with conditions that cause chronic hypoxia, such as chronic lung disease or congenital heart disease. Chronic low oxygen levels can lead to nailbed clubbing as a compensatory response to inadequate oxygenation.

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The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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