Practice Quiz

NCLEX-RN

Category - Reduction of Risk

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A client complains of severe pain in the left flank, nausea, vomiting, and fever. The client reports the voiding of red urine. During the procedure, the nurse’s most important action is to do which of the following?
  1. Strain urine through the use of layers of gauze or a strainer.
  2. Send the specimen to the laboratory right away for analysis.
  3. Instruct the client to limit his fluid intake.
  4. Monitor for hypersensitivity reactions.
Explanation
Answer - A - The client has symptoms of urinary calculi. The nurse should strain the urine for the passage of stones. Sending the specimen to the laboratory is appropriate but it is not the nurse’s immediate concern. The client should be instructed to increase his fluid intake.
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