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

Answer and Explanation

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.

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Correct Answer is C

Explanation

C. Decrease the rate to 27.1 mL/hr until the new bag is brought to the unit: This option is a suitable approach to conserve the remaining TPN solution until the new bag arrives. By halving the infusion rate, the remaining volume of TPN will last longer, ensuring the client continues to receive some nutrition and fluid support while awaiting the delivery of the new bag.
A. While it's important to inform the healthcare team about the low volume of TPN remaining, it may not require immediate physician intervention unless the situation worsens or alternative actions need to be taken.
B. Notifying the pharmacy when the bag is empty is a reasonable action, as they can prepare and deliver the next infusion bag promptly. However, it does not address the immediate need for fluid and nutrition replacement.
D. D10W (dextrose 10% in water) can help prevent hypoglycemia and provide some energy, but it does not provide the full nutritional support that TPN does. However, it can be a reasonable short- term measure while waiting for the replacement TPN bag.

A. Blurred vision, weakness, tingling of extremities B. Hunger, shakiness, confusion C. Thirst, polyuria, abdominal pain D. Tachycardia, oliguria, anxiety

Correct Answer is C

Explanation

C. Thirst, polyuria, and abdominal pain are symptoms commonly associated with hyperglycemia. High blood glucose levels can lead to osmotic diuresis, causing increased urination and thirst. Abdominal pain may occur due to gastrointestinal symptoms related to hyperglycemia, such as bloating or discomfort.
A. Blurred vision, weakness, tingling of extremities are more indicative of hypoglycemia rather than hyperglycemia.
B. Hunger, shakiness, confusion are symptoms of hypoglycemia rather than hyperglycemia.
D. While tachycardia and anxiety can occur with various medical conditions, oliguria is not typically associated with hyperglycemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

What symptoms would indicate to the nurse that the client receiving TPN is experiencing hyperglycemia?

Correct Answer is C

Explanation

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