A nurse is caring for a client with a history of uric acid kidney stones who is experiencing severe flank pain and hematuria. The client's urine output has decreased to 20 mL/hour over the past 4 hours. Which nursing intervention should the nurse implement first?

Decreased urine output (20 mL/hour) indicates potential urinary obstruction, a medical emergency requiring immediate provider notification. Other interventions like pain management or fluid intake are secondary until obstruction is ruled out.

Core Nursing Explanation Key Concept Analysis: This question tests the critical nursing skill of prioritization in a patient with nephrolithiasis (kidney stones). The core issue is the sudden development of Key Point! oliguria (urine output 20 mL/hour) in a patient with known stones and severe pain. This combination strongly suggests a complete or near-complete ureteral obstruction. The pathophysiology involves a stone blocking the ureter, preventing urine flow from the kidney to the bladder. This leads to hydronephrosis (swelling of the kidney) and, if prolonged, can cause permanent kidney damage. The priority is always to ensure patency of the urinary tract and prevent renal injury.

Answer Rationale: The correct answer is to Notify the healthcare provider immediately. A urine output of 20 mL/hr (

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on a medical-surgical unit. Mr. Johnson, 58, was admitted 6 hours ago with severe left flank pain radiating to his groin and visible blood in his urine. He has a known history of gout and uric acid stones. His initial urine output was adequate, but your recent hourly check reveals only 20 mL in the last hour, and he remains in severe pain.

Nursing Intervention Strategy:

1. Immediate Assessment (First 5 minutes): Re-check vital signs (BP may rise due to pain/obstruction, or fall if sepsis develops). Perform a focused assessment: pain location/character, palpate for costovertebral angle (CVA) tenderness. Confirm the low urine output is accurate (check Foley catheter for kinks if present, or ensure urinal is empty).
2. Priority Action (Do Not Delay): Call the healthcare provider or rapid response team per protocol. Report using SBAR: Situation (client with kidney stones), Background (history of uric acid stones), Assessment (new onset oliguria of 20 mL/hr, severe unrelenting pain, hematuria), Recommendation (request urgent evaluation for possible obstruction).
3. Concurrent Supportive Care: While awaiting orders, ensure IV access is patent. You may administer already-prescribed analgesics if available, but do not delay notification. Position for comfort (often lateral or semi-fowler's). Do not encourage oral fluids at this time.
4. After Orders Received: Prepare for possible diagnostics (non-contrast CT scan is gold standard for stones). Assist with procedures (ureteral stent placement). Administer IV fluids if ordered after obstruction is ruled out or relieved. Implement strict I&O (Intake & Output) monitoring.

Patient Safety and Precautions:

• Contraindication: Avoid forcing PO/IV fluids until obstruction is ruled out. Increased fluid load behind a blockage raises renal pressure.
• Medication Caution: NSAIDs (e.g., ketorolac) are excellent for stone pain (reduce inflammation and ureteral edema) but are contraindicated in patients with renal impairment or AKI.
• Key Monitoring: Continuous monitoring of urine output, pain score, vital signs (for fever/sepsis), and serum creatinine/BUN (Blood Urea Nitrogen) to assess for AKI.

Nursing Procedure & Medication Flow Procedure: Urine Strainings

1. Provide patient with a urine strainer (fine-mesh filter) and instruct to void all urine through it.
2. If a stone fragment is caught, place it in a clean, dry container. Label and send to lab for analysis (crucial for guiding long-term prevention).
3. Document the presence/absence of gravel or stones in the urine.

Medication: Allopurinol

• Action: Xanthine oxidase inhibitor. Reduces production of uric acid.
• Nursing Considerations: Monitor for rash (can be severe like Stevens-Johnson syndrome), liver function tests. Encourage adequate hydration to prevent new stone formation. Teach it is for prevention, not acute pain.

A Word from Your Senior Nurse "Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, a sudden drop in urine output is one of the most critical red flags you will see. It's your assessment and prompt action that can prevent a patient from progressing to acute kidney failure. When studying for your boards, don't just memorize 'oliguria is bad' — understand the why: the backup of urine destroys the kidney's delicate filtering units. That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse who acts decisively to protect organ function!"