Question

Which patient will the nurse assess first?

Answer 1

Correct Answers:

28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours

Rationale :

🔹 This patient is the priority because inability to void for 8 hours while receiving opioids suggests acute urinary retention or obstruction, which can lead to hydronephrosis and kidney damage if unaddressed.

🔹 Urolithiasis (stone formation) is associated with severe pain and potential blockage of urine flow; when combined with opioid-induced urinary retention, the risk of bladder distension and renal impairment increases.

🔹 Unlike the other patients, this situation reflects an urgent compromise in elimination that could worsen rapidly.

🔹 Early intervention may require catheterization or imaging to evaluate obstruction.

🔹 Prioritization is based on ABCs and Maslow’s hierarchy, and here, elimination (a physiologic need) is acutely threatened.

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Answer 2

Correct Answers:

Administer morphine sulfate 4 mg IVA

Rationale :

🔸 The patient is experiencing renal colic, which is a severe pain from urolithiasis due to obstruction.

🔸 Pain management is the immediate priority before hydration or diagnostic testing because uncontrolled pain increases stress response, raises blood pressure, and worsens nausea/dizziness.

🔸 After pain relief, secondary measures such as IV fluids and antiemetics can be addressed.

🔸 Pain control also allows the patient to cooperate better with additional diagnostic or therapeutic procedures.

🔸 NCLEX-style priority care often emphasizes stabilizing acute pain and distress before other non-urgent measures.

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Answer 3

Correct Answers:

Replace the catheter, and then obtain a urine specimen for culture.

Rationale :

♦ Patients with long-term indwelling catheters are at high risk for catheter-associated urinary tract infections (CAUTI).

♦ When infection is suspected, cultures must reflect fresh bladder urine, not contaminated samples from the tubing or bag.

♦ Replacing the catheter ensures that the culture is accurate, guiding appropriate antibiotic therapy.

♦ Giving antibiotics before specimen collection risks false-negative cultures, leading to inappropriate treatment.

♦ This action aligns with infection control best practices and CDC guidelines for CAUTI prevention.

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Answer 4

Correct Answers:

Ciprofloxacin

Rationale :

◈ The patient’s findings—pyuria, hematuria, fever, nocturia, elevated WBCs—are consistent with a urinary tract infection or pyelonephritis.

◈ Ciprofloxacin, a fluoroquinolone, is a broad-spectrum antibiotic often prescribed for complicated UTIs.

◈ Medications like oxybutynin or tolterodine treat bladder spasms, not infection, while diuretics like chlorothiazide are unrelated.

◈ Effective treatment must directly target the bacterial cause of the infection to prevent progression to sepsis or renal damage.

◈ This choice reflects the principle of matching therapy with etiology rather than symptom management alone.

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Answer 5

Correct Answers:

Drinking cranberry juice
Avoiding use of douches
Increasing fluid intake

Rationale :

✅ Cranberry juice may reduce bacterial adherence to the bladder wall, lowering recurrence risk.

✅ Avoiding douches reduces introduction of bacteria and disruption of normal vaginal flora, which helps prevent UTIs.

✅ Increasing fluid intake promotes urinary flow, flushing out bacteria and decreasing colonization risk.

✅ These are evidence-based preventive measures emphasized in UTI patient education.

✅ Measures like bubble baths and topical estrogens can actually worsen UTI risk by altering flora and mucosal defenses.

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Answer 6

Correct Answers:

"l will no longer be able to have red wine with my dinner:

Rationale :

🔷 A low-purine diet is crucial in the management of uric acid urolithiasis, as purines metabolize into uric acid, contributing to stone formation.

🔷 Foods and beverages high in purines include red wine, organ meats, sardines, and shellfish, which should be avoided.

🔷 Red wine increases both purine intake and uric acid crystallization, making it a high-risk dietary item.

🔷 By identifying that he must avoid red wine, the patient demonstrates correct understanding of dietary restrictions.

🔷 Patient education on purine sources reduces recurrence risk and prevents kidney injury from repeated stone formation.

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Answer 7

Correct Answers:

"l will use a new, sterile catheter each time I do the procedure."

Rationale :

🔶 Intermittent self-catheterization does not require a new sterile catheter every time, but rather a clean technique with proper handwashing.

🔶 Teaching emphasizes clean intermittent catheterization (CIC) to reduce infection risk and promote independence in patients with neurogenic bladder.

🔶 Reusing the catheter after proper cleaning is safe, whereas insisting on new sterile ones reflects a misunderstanding of the procedure.

🔶 The key infection prevention step is hand hygiene, not sterile supplies, unless otherwise directed in specific clinical settings.

🔶 This statement shows a need for further teaching, since it increases cost and may cause unnecessary stress for the patient.

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Answer 8

Correct Answers:

Instructing the patient to keep out of the sun or to wear protective clothing and use sunscreen
Teaching the patient to swallow extended-release drugs and not to crush or chew the tablets
Reminding the patient to call the prescriber if severe or watery diarrhea develops
Encouraging the patient to drink a full glass of water with each dose and to have a total fluid intake of 3 L daily
Warning the patient not to take the drug within 2 hours of taking an antacid

Rationale :

💠 Photosensitivity is a known side effect of fluoroquinolones, requiring sun avoidance or protective measures.

💠 Extended-release medications must be swallowed whole to preserve their time-release action and prevent toxicity.

💠 Severe diarrhea may indicate C. difficile infection, a serious complication requiring medical intervention.

💠 Adequate hydration (≈3 L/day) helps prevent crystalluria, a complication of this drug class.

💠 Antacids interfere with fluoroquinolone absorption, reducing effectiveness, so separation of doses is essential.

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Answer 9

Correct Answers:

Refer the patient to the clinic health care provider for immediate follow-up.

Rationale :

♦ Pregnant patients with suspected UTIs require prompt medical evaluation because infection can lead to pyelonephritis, preterm labor, and low birth weight.

♦ Delaying treatment or offering only home instructions risks serious maternal-fetal complications.

♦ The nurse’s role is to ensure timely provider intervention rather than offering independent treatment recommendations.

♦ Safe practice involves collaborative care, as medication choices in pregnancy must be carefully prescribed.

♦ This reflects the principle of maternal-fetal safety as the primary concern in prenatal nursing.

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Answer 10

Correct Answers:

Trimethoprim/sulfamethoxazole

Rationale :

🟣 The patient presents with classic UTI symptoms—frequency, urgency, dysuria, and fever—requiring an antibiotic.

🟣 Trimethoprim/sulfamethoxazole is a first-line agent for uncomplicated UTIs due to its effectiveness against common pathogens like E. coli.

🟣 Other listed drugs are not first-line for infection: phenazopyridine only relieves dysuria, nitrofurantoin is preventive post-intercourse, and estrogen is used in postmenopausal women with recurrent UTIs.

🟣 Correct therapy must target the causative bacteria to resolve infection and prevent ascending spread to the kidneys.

🟣 This reflects the nursing priority of ensuring appropriate antimicrobial therapy rather than symptom-only management

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QLexNursing

1 :
Which patient will the nurse assess first?

2 :
Which action will the nurse implement first when the patient with urolithiasis reports spasms of intense flank pain, nausea, and severe dizziness?

3 :
Which nursing action will be priority when the health care provider prescribes a urine culture and antibiotics for the patient presenting With cloudy, blood-tinged urine and a temperature Of 100.1OF (37.80C) after having an indwelling catheter in place for 3 weeks?

4 :
Which medication will the nurse anticipate incorporating into the plan of care for a patient with pyuria, red blood cells in the urine, fever, nocturia, and a white blood cell count of 14,000/gL?

5 :
Which action will the nurse attribute to the alleviation of a patient's urinary tract infection symptoms during a follow-up visit? Select all that apply. One, some, or all responses may be correct.

6 :
Which patient statement indicates effective teaching related to the importance of a low-purine diet in treatment of uric acid urolithiasis?

7 :
Which patient statement indicates a need for additional teaching regarding intermittent self-catheterization for bladder emptying due to neurogenic bladder?

8 :
Which information will the nurse include when teaching a patient regarding fluoroquinolone therapy? Select all that apply. One, some, or all responses may be correct.

9 :
Which nursing action is appropriate when a patient Who is 6 months pregnant comes to the prenatal Clinic With a suspected urinary tract infection (UT l)?

10 :
Which drug Will the nurse anticipate incorporating into the plan Of care for a 32-year-old female patient Who reports urinary frequency, urgency, discomfort upon urination, and a temperature Of 101.20F (38,40C)?

QLexNursing

1 : Which patient will the nurse assess first?

2 : Which action will the nurse implement first when the patient with urolithiasis reports spasms of intense flank pain, nausea, and severe dizziness?

3 : Which nursing action will be priority when the health care provider prescribes a urine culture and antibiotics for the patient presenting With cloudy, blood-tinged urine and a temperature Of 100.1OF (37.80C) after having an indwelling catheter in place for 3 weeks?

4 : Which medication will the nurse anticipate incorporating into the plan of care for a patient with pyuria, red blood cells in the urine, fever, nocturia, and a white blood cell count of 14,000/gL?

5 : Which action will the nurse attribute to the alleviation of a patient's urinary tract infection symptoms during a follow-up visit? Select all that apply. One, some, or all responses may be correct.

6 : Which patient statement indicates effective teaching related to the importance of a low-purine diet in treatment of uric acid urolithiasis?

7 : Which patient statement indicates a need for additional teaching regarding intermittent self-catheterization for bladder emptying due to neurogenic bladder?

8 : Which information will the nurse include when teaching a patient regarding fluoroquinolone therapy? Select all that apply. One, some, or all responses may be correct.

9 : Which nursing action is appropriate when a patient Who is 6 months pregnant comes to the prenatal Clinic With a suspected urinary tract infection (UT l)?

10 : Which drug Will the nurse anticipate incorporating into the plan Of care for a 32-year-old female patient Who reports urinary frequency, urgency, discomfort upon urination, and a temperature Of 101.20F (38,40C)?

1 :
Which patient will the nurse assess first?

2 :
Which action will the nurse implement first when the patient with urolithiasis reports spasms of intense flank pain, nausea, and severe dizziness?

3 :
Which nursing action will be priority when the health care provider prescribes a urine culture and antibiotics for the patient presenting With cloudy, blood-tinged urine and a temperature Of 100.1OF (37.80C) after having an indwelling catheter in place for 3 weeks?

4 :
Which medication will the nurse anticipate incorporating into the plan of care for a patient with pyuria, red blood cells in the urine, fever, nocturia, and a white blood cell count of 14,000/gL?

5 :
Which action will the nurse attribute to the alleviation of a patient's urinary tract infection symptoms during a follow-up visit? Select all that apply. One, some, or all responses may be correct.

6 :
Which patient statement indicates effective teaching related to the importance of a low-purine diet in treatment of uric acid urolithiasis?

7 :
Which patient statement indicates a need for additional teaching regarding intermittent self-catheterization for bladder emptying due to neurogenic bladder?

8 :
Which information will the nurse include when teaching a patient regarding fluoroquinolone therapy? Select all that apply. One, some, or all responses may be correct.

9 :
Which nursing action is appropriate when a patient Who is 6 months pregnant comes to the prenatal Clinic With a suspected urinary tract infection (UT l)?

10 :
Which drug Will the nurse anticipate incorporating into the plan Of care for a 32-year-old female patient Who reports urinary frequency, urgency, discomfort upon urination, and a temperature Of 101.20F (38,40C)?