How it Works
Try Naxlex NCLEX-RN (Free-Trial)

  1. The nurse is caring for an adult client who presents to the clinic who states they have had a fever, chills, frequent urination with burning. The client also reports nausea and vomiting for the last few days. Vitals signs are as follows:

Blood Pressure

118/78 mmHg

Heart Rate

112 beats/minute

Respiratory Rate

22 breaths/minute

Temperature

102.8 F (39.3 C)

WBC

16000 (Ret: 4000-11000)

BUN

24 mg/dL (Ref: 8-20 mg/dL)

Creatinine

1.1 mg/dL (Ref: 0.6-1.2 mg/dL)

What is the priority nursing action?

A.

Assess the client for renal calculi.

B.

Obtain an order for computed tomography (CT scan)

C.

Obtain a urinalysis immediately.

D.

Perform an electrocardiogram STAT

Answer and Explanation

The Correct Answer is C

A. Renal calculi (kidney stones) can cause flank pain and hematuria, but this client’s systemic infection signs (fever, tachycardia, chills, elevated WBC) point toward a urinary tract infection progressing to pyelonephritis, not stones.

B. A CT scan might be used later to assess for obstruction or complications, but it is not the first step. Immediate diagnostic confirmation of infection is needed.

C. The client’s presentation strongly suggests acute pyelonephritis (upper urinary tract infection with systemic involvement). A urinalysis and urine culture are the priority initial diagnostic tests to confirm infection and guide treatment. This should be done before starting antibiotics whenever possible.

D. An EKG may be indicated in cases of electrolyte imbalance (e.g., hyperkalemia in renal failure), but this client’s electrolytes and creatinine are within range. It is not a priority at this time.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

A. An increase in blood pressure to 115/76 mmHg indicates improved circulating volume and perfusion, making this the best indicator of fluid status improvement.
B. A heart rate of 106 beats per minute remains elevated (tachycardia), which does not indicate improvement.
C. A temperature of 101°F reflects infection or fever, not hydration status.
D. A respiratory rate of 18 breaths/minute is within normal range but was already normal before fluids, so it is not the best indicator of fluid balance improvement.

Correct Answer is D

Explanation

A. Acetaminophen is not effective in treating heat stroke, as this condition is not caused by an infection or hypothalamic reset but by failure of thermoregulation.
B. Warm blankets would worsen hyperthermia and are contraindicated in heat stroke.
C. Warm IV fluids would further increase body temperature, worsening the client’s condition.
D. The client is showing signs of heat stroke (very high temperature, confusion, tachycardia, tachypnea, and environmental exposure). The priority intervention is rapid cooling, which includes using cooled IV fluids, cooling blankets, ice packs to the groin/axillae, and removing excess clothing. This helps to lower the dangerously high core temperature and prevent organ failure.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register