What pain description is the client with renal calculi most likely to report during an assessment?
A feeling of pressure in the bladder.
A mild, burning pain when urinating.
Sharp, severe flank pain that occurs suddenly.
A constant, dull, aching pain in the right upper quadrant.
The Correct Answer is C
This is because renal calculi can cause renal colic, which is a sudden and intense pain in the flank area that radiates to the groin or testicles.
The pain is caused by the stone obstructing the ureter and triggering spasms.
Choice A is wrong because a feeling of pressure in the bladder is more likely to indicate a lower urinary tract infection or an overactive bladder.
Choice B is wrong because a mild, burning pain when urinating is more likely to indicate a urinary tract infection or a urethral injury.
Choice D is wrong because a constant, dull, aching pain in the right upper quadrant is more likely to indicate a liver or gallbladder problem.
Normal ranges for urine pH are 4.5 to 8.0, and for specific gravity are 1.005 to 1.030.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Use them only as a last resort after attempting alternatives and get an order to do so. This is because restraints are used to protect persons from harming themselves or others, but they can also cause injuries, falls, and death. Therefore, they should be used only when less restrictive measures fail to protect the person or others, and only with informed consent and a doctor’s order.
Choice A is wrong because restraints should not be secured to the bed rails, but to the movable part of the bed frame out of the person’s reach.
This prevents the person from getting entangled or injured by the restraints.
Choice B is wrong because restraints should not be used for staff convenience or to control or prevent a behavior. They should be used only for the immediate physical safety of the person or others.
Choice C is wrong because restraints should not be applied to clients who have a history of violence or a previous fall for everyone’s protection. They should be used only when there is a clear and present danger of harm to the person or others.
Normal ranges for restraints are:
- Check the person at least every 15 minutes
- Remove restraints and meet basic needs at least every 2 hours
- Apply restraints so that they are snug but allow enough room to fit one finger between the restraint and the wrist
Correct Answer is C
Explanation
This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.
Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.
Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.
This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.
Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.
This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.
Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.
Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.
However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.
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