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

Monitor the client for signs of hemorrhage.

Monitor the incision site for signs of infection.

Monitor the client's urine for sand or gravel.

Monitor the percutaneous nephrostomy tube for signs of obstruction.

Answer and Explanation

The Correct Answer is C

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. .

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Correct Answer is B

Explanation

Choice A rationale

Fatigue can occur in thrombocytopenia due to associated bleeding or anemia, but it is not a hallmark symptom specific to low platelet counts alone. Fatigue relates more to overall systemic effects or concurrent conditions rather than isolated thrombocytopenia. Hemorrhage and petechiae, however, are more directly correlated with reduced platelets in circulation, which compromise clotting and vascular integrity.

Choice B rationale

Hemorrhage is a major concern in thrombocytopenia due to severely reduced platelet counts. Normal platelet levels range from 150,000–450,000/mm³, and values of 18,000/mm³ indicate critical impairment in clot formation, increasing the risk of spontaneous bleeding. Hemorrhagic events in vital organs pose life-threatening consequences, making monitoring and interventions essential to minimize complications associated with uncontrolled bleeding.

Choice C rationale

Petechiae are pinpoint hemorrhages visible on the skin or mucosal surfaces, indicating capillary bleeding due to insufficient platelet-mediated clotting. Normal platelet levels maintain vascular integrity by enabling clot formation, which prevents such microvascular bleeding. Platelet counts as low as 18,000/mm³ lead to abnormal hemorrhagic manifestations, making petechiae a frequent and observable sign in severe thrombocytopenia cases.

Choice D rationale

Headache can occur with thrombocytopenia if intracranial hemorrhage develops, but it is not an expected symptom in all cases. While bleeding risks elevate overall concerns, headache depends on specific organ involvement. Petechiae and systemic hemorrhage are primary symptoms associated with low platelet levels. Headaches without evidence of bleeding do not distinctly correlate with thrombocytopenia diagnosis.

A. Venison stew and ice cream. B. Poached salmon and green beans. C. Spinach salad and rhubarb pie. D. Sautéed mushrooms and fried rice.

Correct Answer is A

Explanation

Choice A rationale

Venison stew and ice cream are high in animal protein and calcium. Excess dietary calcium and animal protein can increase the urinary excretion of oxalate, contributing to kidney stone formation. Hyperoxaluria leads to the precipitation of calcium oxalate crystals in the renal tubules, exacerbating stone development.

Choice B rationale

Poached salmon and green beans are suitable because salmon is low in oxalate content, and green beans are unlikely to contribute significantly to oxalate excretion. Low-oxalate foods help reduce the recurrence risk of kidney stone formation and support overall renal health.

Choice C rationale

Spinach salad and rhubarb pie are rich in oxalate. Spinach contains 970 mg per 100 g, and rhubarb contributes significantly to dietary oxalate, promoting hyperoxaluria and increasing kidney stone risks. These foods should be avoided by individuals prone to oxalate stones.

Choice D rationale

Sautéed mushrooms and fried rice are acceptable choices, as mushrooms have negligible oxalate content and fried rice does not contribute significantly to oxalate excretion. Both options support balanced nutrition while minimizing renal stone risks.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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