The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Rebound tenderness

Sharp, severe pain

Audible thud without pain

Rigidity and firmness

Answer and Explanation

The Correct Answer is B

A. Rebound tenderness is typically associated with peritoneal irritation and is not expected in pyelonephritis. It is more commonly observed in conditions like appendicitis or peritonitis.
B. Sharp, severe pain upon percussion of the costovertebral angle (CVA) is a hallmark sign of pyelonephritis, indicating inflammation or infection in the kidneys. This response, known as CVA tenderness, is a key diagnostic indicator of this condition.
C. An audible thud without pain would be considered a normal finding and does not suggest the presence of pyelonephritis or other kidney-related issues. The absence of pain would likely rule out significant kidney inflammation.
D. Rigidity and firmness are typically associated with muscle guarding or abdominal wall tension rather than kidney involvement. This finding would not be expected in the context of pyelonephritis.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Capillary refill is not the time it takes to return to the client's normal color after releasing pressure
B. Use your thumbnail and press the nailbed proximal to the injury: This is the correct technique for assessing capillary refill. You should press on the nailbed until it blanches and then release the pressure.
C. Pressure placed on the nailbed should cause blanching (pale): When pressure is applied to the nailbed, it should turn pale. This is known as blanching.
D. Capillary refill is measured in seconds: The time it takes for the nailbed to return to its normal color is measured in seconds.
E. Normal should be within 3 seconds or 5 in the older adult: A normal capillary refill time is generally considered to be within 3 seconds. However, in older adults, it may take up to 5 seconds for the nailbed to return to its normal color.

A. Apply warm blankets to both feet. B. Use a doppler ultrasonic stethoscope. C. Notify the healthcare provider. D. Palpate pulse points with legs dependent.

Correct Answer is B

Explanation

A. Applying warm blankets to both feet may help improve circulation but is not the most effective method for locating pedal pulses. This approach does not immediately address the difficulty in palpation.
B. Using a Doppler ultrasonic stethoscope is the appropriate action when pedal pulses are not palpable. The Doppler can detect blood flow in cases where pulses are weak or difficult to feel, making it a vital tool in this scenario.
C. Notifying the healthcare provider is necessary if the Doppler fails to detect pulses, but the initial step should be to use the Doppler to assess the pulses before escalating the situation.
D. Palpating pulse points with the legs dependent may assist in enhancing blood flow to the extremities, but it is less reliable than using a Doppler to detect the pulses when they are not palpable.

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The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D","E"]

Explanation

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

Correct Answer is B

Explanation

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

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