Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?

Evaluate amount of urinary output hourly.

Clamp the catheter for 5 minutes hourly.

Secure the ureteral catheter to the client’s leg.

Report urine leakage around ureteral catheter.

Answer and Explanation

The Correct Answer is D

Choice A reason: Evaluating urinary output hourly monitors renal function post-ureterolithotomy, as obstruction or complications may reduce output. However, urine leakage around the catheter suggests dislodgement or ureteral injury, risking peritonitis or infection. Reporting leakage is more urgent, as it indicates a critical catheter malfunction requiring immediate medical attention.

Choice B reason: Clamping the ureteral catheter risks obstructing urine flow, increasing pressure and causing ureteral damage or reflux, potentially leading to hydronephrosis or infection. Leakage around the catheter is a more pressing issue, indicating possible perforation or displacement, necessitating urgent reporting to prevent severe complications.

Choice C reason: Securing the catheter prevents dislodgement but is routine. Urine leakage suggests a critical issue like catheter malfunction or ureteral injury, which could cause peritonitis or fistula. Reporting leakage takes precedence, as it addresses a potentially life-threatening complication, ensuring timely intervention over standard catheter care.

Choice D reason: Reporting urine leakage is critical, as it may indicate catheter displacement or ureteral perforation, risking peritonitis or infection. Leakage suggests the catheter fails to drain urine properly, a serious post-surgical issue requiring immediate assessment, potentially via imaging or surgical correction, to prevent renal or systemic complications.

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Correct Answer is D

Explanation

Choice A reason: A blood pressure of 100/80 mm Hg is low but not specific for renal perfusion without context. Urinary output directly reflects kidney function, with 30 mL/hour indicating possible oliguria. Monitoring output is critical, per renal assessment and acute kidney injury management protocols in nursing care.

Choice B reason: Abdominal pulse on inspection is unrelated to renal perfusion, typically indicating vascular issues like aneurysms. Urinary output is a direct indicator of kidney function, with 30 mL/hour suggesting reduced perfusion. This is irrelevant, per renal assessment and diagnostic standards in nephrology nursing.

Choice C reason: Urinalysis with 1 to 4 WBC/lpf is within normal range and suggests no infection. Urinary output of 30 mL/hour is concerning for decreased renal perfusion, requiring close monitoring. WBCs are less critical, per renal function and acute kidney injury assessment guidelines in nursing.

Choice D reason: Urinary output of 30 mL/hour indicates possible oliguria, a key sign of decreased renal perfusion. Monitoring this parameter assesses kidney function, guiding interventions to prevent acute kidney injury. It is the most direct indicator, per renal perfusion and critical care protocols in nephrology nursing practice.

A. Oatmeal, raisins, and fruit with skin. B. Potatoes, low-fat breads, and applesauce. C. Chicken, rice, and wheat products. D. Lean beef, salads, and baked potatoes.

Correct Answer is A

Explanation

Choice A reason: Oatmeal, raisins, and fruit with skin are high in fiber, reducing colorectal cancer risk by promoting bowel regularity and reducing carcinogen exposure. This aligns with dietary prevention strategies, per oncology and gastrointestinal health guidelines in nursing education.

Choice B reason: Potatoes, low-fat breads, and applesauce are low in fiber, offering less protection against colorectal cancer. High-fiber foods like oatmeal and fruit are preferred to reduce risk, per dietary recommendations and cancer prevention protocols in nursing care.

Choice C reason: Chicken, rice, and wheat products provide moderate fiber but lack the high-fiber content of oatmeal and fruit with skin, which better reduce colorectal cancer risk. Fiber is key, per oncology and dietary prevention standards in nursing education.

Choice D reason: Lean beef, salads, and baked potatoes offer some benefits, but beef may increase cancer risk. High-fiber oatmeal, raisins, and fruit are more effective for prevention, per colorectal cancer dietary guidelines and oncology prevention protocols in nursing care.

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Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?

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