A female college student comes to the school's health clinic reporting urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
Explanation & Rationale
Choice A reason: Testing the urine for the presence of haematuria is important for diagnosing a urinary tract infection (UTI) or kidney stones, but it is not the most immediate intervention. Haematuria indicates blood in the urine, but assessing the client's vital signs is more urgent to determine if there is an acute issue that requires immediate attention.Choice B reason: Measuring her temperature and heart rate is the most critical first step. These vital signs can provide immediate information about the client's overall condition and help identify potential systemic infection (fever) or hemodynamic instability (tachycardia). This information is essential for prioritizing further interventions and determining the urgency of the situation.Choice C reason: Evaluating the urine for a strong Odor can help identify the presence of a UTI, but it is not as immediately critical as assessing the client's vital signs. Changes in urine Odor can support a diagnosis, but they do not provide the urgent information needed to assess the client's immediate health status.Choice D reason: Palpating the right flank for tenderness is important for assessing kidney involvement, such as in cases of pyelonephritis (kidney infection). However, this physical examination should follow the assessment of vital signs to ensure the client is stable and not in immediate danger.