Difficulty: Medium
Average Score: 87%
Simulated
The nurse is creating a plan of care for a client who has returned to the nursing unit after left nephrectomy. Which assessments should the nurse include in the plan of care? Select all that apply.
Correct answer
A,B,C,E
Rationale
After nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the client's ability to reposition, cough, and deep breathe. Therefore, the next most important measurements are vital signs, pain level, and ability to cough and deep breathe. Clear liquids are not given until the client has bowel sounds.