The nurse is caring for a client after receiving extracorporeal shock wave lithotripsy (ESWL). Which of the following actions should the nurse take?

Choice A rationale

Hemorrhage is not a typical complication of extracorporeal shock wave lithotripsy (ESWL), as it is a non-invasive procedure targeting kidney stones using shock waves. The risk of significant bleeding is minimal, and monitoring focuses more on urinary changes or localized pain rather than hemorrhage.

Choice B rationale

ESWL does not involve surgical incisions, so there is no incision site to monitor for infection. This action is irrelevant to the procedure's mechanism, which uses external shock waves to fragment stones rather than invasive surgical methods.

Choice C rationale

Sand or gravel in the urine is a common finding after ESWL as the procedure fragments kidney stones into smaller particles. These fragments are excreted through the urinary system. Monitoring urine for these particles helps evaluate the procedure's effectiveness and ensure stones are adequately eliminated.

Choice D rationale

Percutaneous nephrostomy tubes are used for urinary drainage but are not a standard component of ESWL. Monitoring for tube obstruction applies to invasive procedures, whereas ESWL focuses on non-invasive stone fragmentation. This action is unrelated to the client's current treatment modality. .

Choice A rationale

Asking about medication use for headaches provides insights into pain management strategies but does not directly address underlying causes of symptoms. Vision changes and headaches may indicate neurological or cardiovascular issues, which require immediate investigation of vital signs like blood pressure to rule out hypertension or increased intracranial pressure.

Choice B rationale

Referring the client to an eye specialist addresses vision changes but neglects the acute nature of headaches. Hypertension or elevated intracranial pressure can affect both vision and cause headaches, and immediate assessment of these factors through blood pressure is more urgent.

Choice C rationale

Obtaining blood pressure evaluates for hypertension, which can manifest with headaches and visual disturbances due to increased arterial pressure affecting cerebral and ocular vessels. Normal blood pressure ranges are typically 120/80 mmHg. Immediate blood pressure measurement prioritizes acute care and mitigates potentially life-threatening conditions.

Choice D rationale

Obtaining a full history and physical is valuable for comprehensive care but delays immediate assessment of critical symptoms such as visual changes and headaches. Measuring blood pressure provides faster evaluation of acute conditions like hypertensive crisis or stroke risk.