Author Question: After change-of-shift report, which patient should the nurse assess first? a. Patient with a ... (Read 104 times)

itsmyluck · **on:** Jun 25, 2018

After change-of-shift report, which patient should the nurse assess first?

a. Patient with a urethral stricture who has not voided for 12 hours
b. Patient who has cloudy urine after orthotopic bladder reconstruction
c. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg
d. Patient who voided bright red urine immediately after returning from lithotripsy

Question 2

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first?

a. Check blood pressure and heart rate.
b. Administer morphine sulfate 4 mg IV.
c. Transport to radiology for an intravenous pyelogram.
d. Insert a urethral catheter and obtain a urine specimen.

dreamfighter72 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The patient information suggests acute urinary retention, a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will also be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or possible intervention.

Answer to Question 2

ANS: A
Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions are also important once the patient's cardiovascular status has been determined and stabilized.