The nurse is caring for a client who had a nephrectomy after having massive trauma to the kidney. Which of the following assessment findings obtained postoperatively is most important to communicate to the surgeon?
A)Blood pressure is 102/58.
B)Incisional pain level is 8/10.
C)Urine output is 20 mL/hour for 2 hours.
D)Crackles are heard at both lung bases.

Question

Quizplus · Accepted Answer

Because the urine output should be at least 0.5 mL/kg/hour, a 40 mL output for 2 hours indicates that the client may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The client should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life-threatening as decreased renal perfusion. In addition, the nurse can medicate the client for pain.

The Nurse Is Caring for a Client Who Had a Nephrectomy