While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

Stone fragments are collected when straining the client's urine.

Client denies urinary frequency, urgency, or dysuria.

Urine is pale pink with no observable blood clots.

Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.

Answer and Explanation

The Correct Answer is A

A.   This directly indicates that the lithotripsy procedure was successful in breaking down the stone into smaller fragments that can be passed through the urinary tract.
B.   While the absence of these symptoms is a positive sign, it does not directly confirm the success of the lithotripsy procedure. These symptoms can be present even if the stone has been broken down.
C.   Pale pink urine is expected after lithotripsy due to minor bleeding. The absence of blood clots is also a good sign, but it doesn't definitively confirm the procedure's success.
D.   Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits. These lab values are important indicators of kidney function but do not directly relate to the success of the lithotripsy procedure itself.

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Correct Answer is C

Explanation

A. While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B. These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C. Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D. Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

A. Watch for shortness of breath which may indicate a fat embolus. B. Begin range of motion exercises within the first 24 hours. C. Apply ice intermittently for the first 24 hours. D. After edema subsides, apply heat continuously.

Correct Answer is C

Explanation

A. While it's important to monitor for complications, this is not a typical initial instruction for a soft tissue injury.
B. Early range of motion exercises are generally not recommended for acute soft tissue injuries, as they can increase swelling and pain.
C. This is the correct instruction. Applying ice to the injured area helps reduce swelling and pain. It should be applied intermittently to prevent tissue damage from excessive cold.
D. Heat is typically used in the later stages of healing to promote blood flow and relaxation, but continuous heat application can be harmful in the acute phase.

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While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

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Naxlex Comprehensive Predictor Exams

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