A nurse cares for a client who is recovering from a closed ...

[shenderson6]

A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, My pain has suddenly increased from a 3 to a 10 on a scale of 0 to 10. Which action should the nurse take first?
 
  a. Reposition the client on the operative side.
  b. Administer the prescribed opioid analgesic.
  c. Assess the pulse rate and blood pressure.
  d. Examine the color of the client's urine.

Question 2

A nurse obtains a sterile urine specimen from a client's Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next?
 
  a. Clamp another section of the tube to create a fixed sample section for retrieval.
  b. Insert a syringe into the injection port and aspirate the quantity of urine required.
  c. Clean the injection port cap of the drainage tubing with povidone-iodine solution.
  d. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.

[Viet Thy]

Answer to Question 1

ANS: C
An increase in the intensity of pain after a percutaneous kidney biopsy is a symptom of internal hemorrhage. A change in vital signs can indicate that hemorrhage is occurring. Before other actions, the nurse must assess the client's hemodynamic status.

Answer to Question 2

ANS: C
It is important to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic, such as povidone-iodine solution or alcohol. This will help prevent surface contamination before injection of the syringe. The urine sample should be collected directly from the catheter; therefore, a second clamp to create a sample section would not be appropriate. Every sample from the catheter is usable; there is the need to discard the first sample.

[shenderson6]

TYSM

[anyusername12131]

Gracias!