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?

Assess the client for renal calculi.

Obtain an order for computed tomography (CT scan)

Obtain a urinalysis immediately.

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.

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Correct Answer is C

Explanation

A. The varicella (chickenpox) vaccine is not appropriate for an older adult who already had chickenpox and is now presenting with shingles (herpes zoster).
B. Antibiotics are not indicated; shingles is caused by a virus (varicella-zoster virus), not bacteria.
C. The zoster vaccine is recommended after recovery to help prevent future episodes and reduce the risk of complications such as postherpetic neuralgia.
D. Shingles is not sexually transmitted, so avoiding sexual activity is unnecessary.

A. "It is important to continue to keep my baby's immunizations current." B. "I may give my baby a bottle of formula in bed at nap-time for comfort." C. "Immediately return to the emergency department if a tube ever falls out." D. Report any incidents of purulent drainage to the health care provider." E. "I can save the leftover antibiotic to use whenever the tubes are draining."

Correct Answer is ["A","D"]

Explanation

A. Keeping immunizations up to date, especially pneumococcal and influenza vaccines, helps prevent recurrent ear infections that can lead to complications.
B. Bottles in bed increase the risk of otitis media due to pooling of formula in the nasopharynx and eustachian tube, and should be avoided.
C. Tubes are expected to fall out spontaneously within 6–12 months; this is not an emergency. Parents should simply notify the provider at the next follow-up.
D. Purulent drainage may indicate an infection and should be reported promptly to the health care provider for evaluation and possible treatment.
E. Leftover antibiotics should never be saved or reused without medical direction, as improper use can lead to resistance or ineffective treatment.

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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)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an older adult client who states that they have a rash that is burning and painful. Upon assessment the nurse notes round, red, vesicles on one dermatome on the right side. What is the most important discharge teaching?

Correct Answer is C

Explanation

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Correct Answer is ["A","D"]

Explanation

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