Following a nephrectomy, which assessment finding is most important in determining nursing care for the client?
A) Urine output of 35 to 40 mL/hour
B) Pain of 3 out of 10, 1 hour after analgesic administration
C) SpO2 at 90% with fine crackles in the lung bases
D) Blood tinged drainage in Jackson-Pratt drainage tube
C
Feedback:
The Risk for Ineffective Breathing Pattern is often a challenge in caring for clients post nephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sounds. Intake and output is monitored to maintain a urine output of greater than 30 mL/hour. Pain control is important and should allow for movement, deep breathing, and rest. Blood-tinged drainage from the JP tube is expected in the initial postoperative period.
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