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 D

Explanation

Choice A rationale

Serum electrolytes provide valuable information about fluid and electrolyte balance but are not specific markers for heart failure. Electrolyte abnormalities, such as hyponatremia, may occur but are secondary findings. Direct markers like BNP levels are more diagnostic for heart failure.

Choice B rationale

A complete blood count is used to assess infection, anemia, or inflammation but does not directly diagnose heart failure. It lacks specificity for cardiac function evaluation. Targeted testing ensures effective diagnosis and management.

Choice C rationale

Blood urea nitrogen measures renal function and is not a primary marker for heart failure. Elevated BUN may result from renal hypoperfusion secondary to heart failure but is not a definitive diagnostic indicator. Specific cardiac markers are required.

Choice D rationale

Brain natriuretic peptide is a hormone released in response to ventricular stretch from volume overload, characteristic of heart failure. Elevated BNP levels strongly correlate with heart failure severity and guide diagnosis. Normal BNP levels are typically <100 pg/mL. This test is highly specific for heart failure. .

A. Reports of malaise. B. Chills. C. Reports of dysuria. D. High fever. E. Reports of urinary frequency.

Correct Answer is ["C","E"]

Explanation

Choice A rationale

Malaise is more associated with systemic conditions, such as upper urinary tract infections or generalized illness, rather than isolated lower urinary tract infections. Lower UTIs tend to present with localized urinary symptoms rather than systemic effects.

Choice B rationale

Chills suggest systemic involvement and are characteristic of pyelonephritis or upper urinary tract infections. Lower UTIs typically do not produce systemic signs like chills, as the infection is confined to the bladder and urethra.

Choice C rationale

Dysuria is a classic symptom of lower UTIs. It results from inflammation of the bladder mucosa due to the presence of pathogenic organisms. The irritation of the urinary tract leads to painful or difficult urination, confirming the diagnosis of lower UTI.

Choice D rationale

High fever, like chills, is indicative of upper urinary tract infections, such as pyelonephritis. Lower UTIs are generally afebrile, presenting more with localized urinary symptoms rather than systemic manifestations.

Choice E rationale

Urinary frequency is another hallmark symptom of lower UTIs, caused by bladder irritation. The infection leads to an increased urge to urinate, even when little urine is produced. This symptom is specific to lower UTIs and supports the diagnosis when present.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["C","E"]

Explanation

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