A client who has a confirmed urinary stone in the proximal left ureter undergoes extracorporeal shock- wave lithotripsy. What Information is most Important for the nurse to collect after lithotripsy?
Urine specific gravity and antigen levels
Urine characteristics and output
Appearance of the surgical site
Results of clean catch urine specimens
The Correct Answer is B
B. After ESWL for a urinary stone, it is essential to monitor the client's urine characteristics (such as color, clarity, and presence of blood) and output. The presence of hematuria is a common and expected finding after ESWL due to the disruption of tissue and blood vessels during the procedure. Monitoring urine output helps assess renal function and ensures adequate hydration, which is crucial for flushing out stone fragments.
A. While monitoring urine specific gravity can provide information about the concentration of urine, and assessing antigen levels may be relevant in certain contexts, these parameters are not typically the most important information to collect immediately after extracorporeal shock-wave lithotripsy (ESWL) for a urinary stone.
C. While it is important to monitor the surgical site for signs of infection or complications after any procedure, ESWL is a non-invasive procedure performed externally, typically without any incisions.
D. While obtaining clean catch urine specimens for urinalysis and culture may be relevant for assessing urinary tract infection or other urinary abnormalities, it is not typically the most important information to collect immediately after ESWL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Crohn's disease exacerbation often leads to malnutrition due to decreased oral intake, malabsorption, and increased nutrient losses through diarrhea. Addressing imbalanced nutrition is crucial to replenish depleted nutrient stores, support healing, and prevent further complications.
A. While fluid overload can be a concern in certain situations, such as when administering intravenous fluids or in clients with renal impairment, it is not typically a primary concern in clients hospitalized with Crohn's disease exacerbation. Crohn's disease is more commonly associated with dehydration due to diarrhea and malabsorption rather than fluid overload.
B. In the acute phase of Crohn's disease exacerbation, addressing immediate physiological needs and stabilizing the client's condition typically take precedence over psychosocial concerns.
D. Social isolation can be a concern for clients with chronic illnesses, including Crohn's disease, as it may impact their quality of life and emotional well-being. However, in the acute phase of exacerbation, addressing physiological needs and stabilizing the client's condition typically takes precedence over psychosocial concerns such as social isolation.
Correct Answer is A
Explanation
A. Hemoglobin 7.8: This finding indicates a low hemoglobin level, which suggests significant blood loss, likely due to the actively bleeding peptic ulcer. Hemoglobin levels below normal can indicate anemia, and a level of 7.8 is particularly concerning. This finding should be immediately reported to the physician because it suggests ongoing bleeding and the need for intervention to stabilize the client's hemoglobin levels and prevent further complications such as hypovolemic shock.
B. Blood pressure = 118/78: This blood pressure reading falls within the normal range for most adults. While monitoring blood pressure is important, this finding alone may not be immediately concerning in the context of a bleeding peptic ulcer.
C. The presence of occult blood in the stool suggests gastrointestinal bleeding, which is consistent with the actively bleeding peptic ulcer. While this finding is significant, it may not require immediate reporting to the physician as it is expected in the context of the client's condition.
D. Epigastric pain is a common symptom of peptic ulcer disease, and worsening pain on palpation may indicate peritonitis or perforation, which are serious complications of peptic ulcers. However, if the pain is severe or associated with signs of peritonitis it should be promptly reported to the physician for further evaluation and management.
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