In assessing a client 6 hours after a radical nephrectomy for renal cell carcinoma, the nurse notes that the client's blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour
Which is the nurse's best action? a. Position the client so that the remaining kidney is not dependent.
b. Measure the specific gravity of the client's urine.
c. Document the findings in the client's record.
d. Assess the pulse rate and quality, and then notify the provider.
D
The nurse should fully assess the client for signs of volume depletion and shock, then should no-tify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is partic-ularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Documentation is critical but is not the priority at this time. The other two options would not be helpful interventions.
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