# A nurse is caring for a client with a history of calcium oxalate kidney stones who is experiencing severe flank pain and hematuria. Which nursing action should be the highest priority to ensure client safety?

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> subject: Adult Health

## 문제

A nurse is caring for a client with a history of calcium oxalate kidney stones who is experiencing severe flank pain and hematuria. Which nursing action should be the highest priority to ensure client safety?

## 보기

1. Encourage increased fluid intake to 3-4 liters per day
2. Administer prescribed analgesics for pain management
3. Strain all urine and monitor for stone passage **✔ 정답**
4. Provide a low-calcium diet education

**정답: 3**

## 해설

Straining all urine is the highest priority safety intervention to monitor for stone passage, detect complications like obstruction, and collect stones for analysis. Other interventions like fluid intake and pain management are important but secondary to safety monitoring.

## 심화 해설

Clinical Priority Analysis

When a client with a known history of calcium oxalate stones presents with severe flank pain and hematuria, the nurse must immediately recognize this as a probable acute obstructive stone episode. While all listed interventions are relevant to the overall care of a patient with urolithiasis, the NCLEX-RN prioritization framework requires identifying the action that directly addresses an immediate physiological threat to client safety.

Why Straining Urine Is the Highest Priority

The primary safety risk in this acute presentation is the potential for complete urinary tract obstruction, which can lead to hydronephrosis, irreversible kidney damage, and urosepsis. The act of straining all urine and monitoring for stone passage is the only intervention listed that provides direct, objective diagnostic data to confirm that the obstruction is resolving. Capturing the stone allows for laboratory analysis of its composition. This analysis is not merely a diagnostic formality; it is the definitive guide for all subsequent, long-term preventive therapies. Without knowing the stone's exact composition, dietary and pharmacological advice may be ineffective or even harmful. From a safety standpoint, failure to confirm stone passage could result in a clinician assuming the acute event has resolved when a silent obstruction persists, delaying critical urological intervention.

Analysis of Other Options

- Option 1 (Encourage increased fluid intake): While a cornerstone of prevention, as supported by the evidence noting that adequate fluid intake is a "cornerstone of prevention" for urinary calculi [1], this is a long-term management strategy. During an acute obstructive episode with severe pain, forcing large volumes of oral fluid can be contraindicated as it may increase hydrostatic pressure proximal to the obstruction, exacerbating pain and hydronephrosis. This intervention is prioritized after the acute obstruction is managed or ruled out.

- Option 2 (Administer prescribed analgesics): Pain management is a high priority, but it addresses the client's comfort, not the underlying pathophysiological threat of obstruction. The NCLEX-RN framework places physiological safety (airway, breathing, circulation, and in this case, prevention of organ damage) above comfort. Administering analgesics is a dependent nursing action that should occur concurrently but is not the highest safety priority over a direct assessment measure that evaluates the cause of the pain.

- Option 4 (Provide a low-calcium diet education): This is an outdated and potentially harmful recommendation for calcium oxalate stone formers. Current evidence-based guidelines do not support a generalized low-calcium diet, as dietary calcium actually binds oxalate in the gut, preventing its absorption and subsequent urinary excretion. More importantly, providing dietary education is a long-term, preventive intervention that is inappropriate during the acute, severe pain phase. The immediate focus must be on diagnosis and confirming the passage of the current stone, which will then dictate the correct dietary advice based on its composition.

Pathophysiology and Clinical Reasoning Link

The severe flank pain indicates ureteral spasm and stretching of the renal capsule as the stone obstructs the flow of urine. Hematuria results from the stone lacerating the urothelium. The nurse's highest priority is to obtain the physical evidence (the stone) that confirms the diagnosis and signals the end of the acute obstructive event. This action directly informs all other aspects of care, from confirming the safety of increasing fluids to tailoring the prevention plan that addresses the high recurrence rates of up to 50% within 10 years [1].References (research sources)

- [1]Developing and Evaluating a WeChat-Based Applet Fluid Intake Reminder on Enhancing Fluid Adherence in Postoperative Patients With Urinary Calculi: Protocol for a Randomized Controlled Trial.RCT/clinical trialZhou X, Wang T, Chen Q. (2026) · DOI: 10.2196/80214

## 임상 시나리오

Acute Renal Colic: Priority Nursing ActionConfirming stone passage is the top safety priority
For a client with known calcium oxalate stones presenting with severe flank pain and hematuria, the immediate safety risk is urinary tract obstruction leading to hydronephrosis or urosepsis.

The highest priority action is to strain all urine. Capturing the stone provides objective evidence that the obstruction is resolving and allows for composition analysis, which is the definitive guide for all long-term preventive therapy.

CautionDo not assume the episode is over when pain subsides. A silent obstruction can persist and cause irreversible kidney damage. Document and report any absence of stone passage.

## 핵심 개념

- **Hydronephrosis** — Swelling of a kidney due to a build-up of urine, caused by an obstruction in the urinary tract.
- **Urosepsis** — A systemic infection originating from the urinary tract that has spread into the bloodstream, a life-threatening complication of obstruction.
- **Calcium Oxalate Stones** — The most common type of kidney stone, formed from calcium and oxalate; dietary management focuses on normal calcium intake and reducing oxalate-rich foods.
- **Straining Urine** — The process of passing all urine through a filter or strainer to capture any passed stones or fragments for laboratory analysis.

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