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 C

Explanation

Choice A reason: Dry skin and inelastic turgor reflect dehydration in DI from antidiuretic hormone deficiency, causing water loss. This is less urgent than hypernatremia (185 mEq/L), which dehydrates brain cells, risking seizures or coma, requiring immediate fluid correction to prevent neurological damage in this critical condition.

Choice B reason: Tachycardia (110 beats/minute) compensates for hypovolemia in DI, where water loss reduces preload, triggering sympathetic activation. This is less critical than hypernatremia (185 mEq/L), which causes cerebral dehydration, necessitating urgent hypotonic fluids to prevent neurological complications, making heart rate secondary.

Choice C reason: Serum sodium of 185 mEq/L indicates severe hypernatremia in DI, where water loss concentrates sodium, dehydrating neurons and risking seizures or coma. Immediate IV hypotonic fluids (e.g., 5% dextrose) correct osmolarity, preventing life-threatening cerebral complications, addressing the urgent pathophysiological crisis in DI.

Choice D reason: Polyuria and thirst are hallmark DI symptoms from water loss but expected and less urgent than hypernatremia (185 mEq/L), which threatens neurological function via osmotic brain injury. Correcting sodium is critical to prevent seizures, making these symptoms secondary to urgent electrolyte management.

A. Acetaminophen 650 mg PO PRN. B. Olanzapine 30 mg PO at bedtime. C. Thiamine, USP 100 mg PO daily. D. Ondansetron 8 mg IV PRN.

Correct Answer is A

Explanation

Choice A reason: Acetaminophen is hepatotoxic, metabolized by the liver via cytochrome P450 to NAPQI, which depletes glutathione, causing necrosis in hepatitis. A compromised liver from alcohol or viral hepatitis increases toxicity risk, even at standard doses. Contacting the provider ensures safer analgesics, preventing further liver damage in this high-risk client.

Choice B reason: Olanzapine, an antipsychotic, manages schizophrenia by blocking dopamine D2 receptors. It is metabolized by the liver but has low hepatotoxicity risk compared to acetaminophen in hepatitis. No immediate contraindication exists, as it controls psychosis without significantly worsening liver function, making it safe to administer without delay.

Choice C reason: Thiamine (vitamin B1) is essential in hepatitis, particularly with alcohol abuse, preventing Wernicke’s encephalopathy from deficient glucose metabolism. It is liver-safe and beneficial, supporting neurological function without toxicity. Administering thiamine is appropriate, making it unnecessary to contact the provider before implementation.

Choice D reason: Ondansetron, an antiemetic, controls nausea in hepatitis via serotonin 5-HT3 receptor blockade. It is metabolized by the liver but has minimal hepatotoxicity, safe in liver disease. No contraindication exists, as it alleviates symptoms without worsening hepatitis, unlike acetaminophen, which poses significant liver risk.

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

Nursing Test Bank

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