The nurse is providing care for a patient admitted with severe flank pain identified as renal colic. Urinalysis is positive for microscopic hematuria. Which action should the nurse take?
Maintain IV fluids and encourage oral fluids
Promote assisted ambulation as tolerated
Strain urinary output and observe for stones
Administer prescribed narcotic medication
The Correct Answer is C
Choice a reason: Maintaining IV fluids and encouraging oral fluids is important for patients with renal colic to ensure hydration and facilitate the passage of kidney stones. However, it is not the most immediate action to take for managing the patient's current condition, which includes severe pain and hematuria.
Choice b reason: Promoting assisted ambulation as tolerated can help in the movement and passage of kidney stones. Nevertheless, it is not the priority action to take initially when the patient is experiencing severe pain and there is a need to identify the cause of the hematuria.
Choice c reason: Straining urinary output and observing for stones is the most appropriate initial action. This allows the nurse to collect any stones that pass, which can then be analyzed to determine their composition. Understanding the type of stone can help in planning further treatment and preventive measures. Identifying and collecting the stones is crucial for proper diagnosis and management of renal colic.
Choice d reason: Administering prescribed narcotic medication is essential for managing severe pain associated with renal colic. Pain management is a critical component of care. However, while it is necessary, it should be accompanied by straining the urine to detect any stones and understand the underlying cause of the symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a reason: Wearing cotton underwear is recommended to reduce the risk of urinary tract infections (UTIs). Cotton is breathable and helps keep the genital area dry, preventing the growth of bacteria. This choice of underwear is actually a preventative measure against UTIs rather than a risk factor.
Choice b reason: Having a healthy immune system is protective against infections, including UTIs. A strong immune system helps the body fight off bacteria that may enter the urinary tract, reducing the likelihood of developing an infection. Therefore, it is not a risk factor for UTIs.
Choice c reason: Drinking plenty of water is a preventive measure for UTIs. Adequate hydration helps flush out bacteria from the urinary tract through frequent urination, reducing the risk of infection. Encouraging fluid intake is an important strategy in preventing UTIs.
Choice d reason: Frequent sexual activity is a well-known risk factor for UTIs. Sexual intercourse can introduce bacteria into the urinary tract, increasing the risk of infection. This is especially common in women due to the shorter length of the urethra. Proper hygiene practices, such as urinating after intercourse, can help mitigate this risk.
Correct Answer is D
Explanation
Choice a reason: White rice is not a significant source of potassium. While it provides carbohydrates and some vitamins, it does not help to increase potassium levels, which is crucial for a client taking furosemide, a diuretic that can cause potassium depletion.
Choice b reason: Cheddar cheese, while nutritious, is also low in potassium. It provides calcium and protein but does not significantly contribute to increasing potassium levels. For clients needing to boost their potassium intake, other foods rich in potassium are more appropriate.
Choice c reason: Cabbage, although a healthy vegetable, is not high in potassium. It offers vitamins and fiber but does not provide the necessary potassium levels needed for someone with a low serum potassium level. Hence, it is not the best option for this client's dietary needs.
Choice d reason: Bananas are an excellent source of potassium and are recommended for clients with low potassium levels. Furosemide can deplete potassium, and bananas can help replenish this essential mineral. Including bananas in the client's daily diet is effective in maintaining appropriate potassium levels.
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