While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?
Stone fragments are collected when straining the client's urine.
Client denies urinary frequency, urgency, or dysuria.
Urine is pale pink with no observable blood clots.
Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.
The Correct Answer is A
A. This directly indicates that the lithotripsy procedure was successful in breaking down the stone into smaller fragments that can be passed through the urinary tract.
B. While the absence of these symptoms is a positive sign, it does not directly confirm the success of the lithotripsy procedure. These symptoms can be present even if the stone has been broken down.
C. Pale pink urine is expected after lithotripsy due to minor bleeding. The absence of blood clots is also a good sign, but it doesn't definitively confirm the procedure's success.
D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits. These lab values are important indicators of kidney function but do not directly relate to the success of the lithotripsy procedure itself.
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Related Questions
Correct Answer is D
Explanation
A. While pain assessment is important, it's not the priority in this situation. Pain can be present in various conditions, and it doesn't necessarily indicate DVT.
B. Elevating the leg can help reduce swelling but is not the initial action. The nurse needs to rule out a serious condition like DVT first.
C. Applying ice and an elastic bandage might be appropriate for some types of swelling but is not the correct initial action for a sudden, unilateral leg swelling.
D. The client presents with sudden, unilateral leg swelling, which is a red flag for deep vein thrombosis (DVT). DVT is a serious condition that can lead to pulmonary embolism. Therefore, the nurse's priority is to assess for signs of inflammation, which are warmth and erythema.
Correct Answer is A
Explanation
A. This is the most crucial information to provide. A scleral buckling procedure is performed to repair a retinal detachment. Any signs of detachment recurrence are critical and should be reported immediately. Directly addresses the primary goal of the surgery.
B. While maintaining the head in a specific position is often recommended post-surgery, it's not the most critical information in this context. The focus should be on identifying potential complications. Not as critical as the other options.
C. Infection is a potential complication of any surgery, but it's not the primary concern immediately post-scleral buckling. Important but not the most critical information.
D. Ambulation is generally encouraged to prevent complications like pneumonia and deep vein thrombosis, but it's not a specific concern immediately post-scleral buckling. Not directly related to the procedure.
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