A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the client's postprocedural care?
Manage bladder irrigation following the procedure.
Administer a bolus of 750 mi. normal saline following the procedure
Strain the client's urine following the procedure.
Insert a urinary catheter for 24 to 48 hours after the procedure.
The Correct Answer is C
A. Manage bladder irrigation following the procedure. - Bladder irrigation is not typically performed after ESWL. It may be used in other urological procedures, but it is not a standard post-procedural care for ESWL.
B. Administer a bolus of 750 mL normal saline following the procedure. - While maintaining hydration is important, there is no specific requirement for a bolus of normal saline after ESWL. Hydration is usually encouraged, but the amount and method of administration are determined based on the client's overall fluid status and medical condition.
C. Strain the client's urine following the procedure.
After extracorporeal shock wave lithotripsy (ESWL), it is essential to strain the client's urine to collect any stone fragments. Straining allows healthcare providers to analyze the composition of the stones, ensuring that all fragments have been passed. This information helps in assessing the effectiveness of the procedure and guides further management.
D. Insert a urinary catheter for 24 to 48 hours after the procedure. - Inserting a urinary catheter is not a routine post-procedural measure after ESWL. Catheterization might be necessary in certain situations or for specific medical reasons, but it is not a standard practice after ESWL for all clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Performing range of motion:
Explanation: Range of motion exercises are important for preventing joint stiffness and muscle atrophy, especially in clients with casts. However, this is not the first priority. Ensuring adequate circulation and perfusion is crucial before initiating any exercises or movements, as compromised circulation could lead to serious complications.
B. Managing pain:
Explanation: Pain management is important for the client's comfort, but it is not the first priority in this context. Assessing circulation and ensuring there are no signs of compromised perfusion takes precedence. Pain management can follow once circulation has been confirmed as adequate.
C. Checking capillary refill:
Explanation: Checking capillary refill is the first priority when assessing a client with a cast. Capillary refill assesses peripheral circulation by pressing on the nail bed and observing how quickly color returns. Delayed capillary refill could indicate compromised blood flow, which is a serious concern and requires immediate intervention.
D. Discussing cast care:
Explanation: Educating the client about cast care is important, but it is not the first priority. Ensuring proper circulation and ruling out any signs of impaired perfusion must be addressed before discussing cast care instructions.
Correct Answer is B
Explanation
A. Recent travel: Assessing recent travel history is relevant in understanding potential exposure to certain infections or dietary habits specific to certain regions. However, for a client admitted with renal stones, the immediate focus is on understanding factors related to their condition. While travel history might be a part of the overall assessment, it is not the priority question in this context.
B. Typical diet and fluid intake history: This is the priority question. Understanding the client's typical diet, including the types of foods they consume and their fluid intake habits, is crucial. Certain dietary factors, such as high intake of oxalate-rich foods or insufficient fluid intake, can contribute to the formation of renal stones. Gathering this information helps healthcare providers identify potential dietary factors that might have led to the stones, allowing for tailored dietary recommendations and prevention strategies.
C. Vaccination records: Vaccination records are essential for preventive healthcare, but they are not directly related to the assessment of a client admitted with renal stones. While ensuring clients are up-to-date with vaccinations is important, it is not the immediate concern in the context of renal stones.
D. Last bowel movement: Bowel movements are relevant to overall health and can provide information about gastrointestinal function. However, in the specific context of assessing a client admitted with renal stones, understanding the client's bowel movements is not the primary concern. The focus should be on factors directly related to renal stones, such as diet and fluid intake history, which can inform immediate interventions and prevention strategies.
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