# A client with a 6mm calcium oxalate kidney stone in the ureter is experiencing severe flank pain and nausea. The healthcare provider has prescribed conservative management. Which nursing intervention should the nurse prioritize?

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## 문제

A client with a 6mm calcium oxalate kidney stone in the ureter is experiencing severe flank pain and nausea. The healthcare provider has prescribed conservative management. Which nursing intervention should the nurse prioritize?

## 보기

1. Restrict fluid intake to prevent stone movement
2. Encourage increased fluid intake to 3-4 liters per day **✔ 정답**
3. Administer antibiotics to prevent infection
4. Prepare the client for immediate surgical intervention

**정답: 2**

## 해설

Increased fluid intake is prioritized in conservative management to facilitate stone passage and prevent further formation. Pain management and monitoring for complications are also important.

## 심화 해설

Understanding the Clinical Scenario

The client presents with a 6mm calcium oxalate stone lodged in the ureter, accompanied by severe flank pain and nausea. The prescription for conservative management indicates the provider has determined the stone is small enough to pass spontaneously without immediate surgical intervention. In the context of conservative management for urolithiasis, the primary goal is to facilitate stone passage while managing symptoms and preventing complications.

Prioritizing Nursing Interventions

Among the listed options, the nurse's priority is to encourage increased fluid intake. The rationale is grounded in the pathophysiology of stone formation and passage. Renal stones develop when urinary solutes, such as calcium and oxalate, crystallize into solid deposits within the urinary tract [2]. By significantly increasing fluid intake to 3-4 liters per day, the nurse promotes high urine output. This hemodilution reduces the concentration of lithogenic solutes, preventing further crystal aggregation and stone growth. More critically, the increased hydrostatic pressure generated by high urine flow behind the stone helps propel it distally through the ureter, facilitating its passage into the bladder. This intervention directly addresses the underlying problem and aligns with the goals of conservative therapy.

Analysis of Incorrect Options

- Option 1 (Restrict fluid intake): This action is contraindicated. Fluid restriction would lead to concentrated urine, which promotes further crystallization and stone growth. It would also reduce the hydraulic force needed to move the existing stone, potentially worsening the obstruction and pain.

- Option 3 (Administer antibiotics): While complex or obstructing stones pose a risk for urinary tract infection, there is no indication in the scenario that the client has an active infection. Prophylactic antibiotic administration is not a standard component of conservative management for a non-infected stone and would contribute to antimicrobial resistance. The focus of conservative management is mechanical passage, not infection prophylaxis without clinical evidence .

- Option 4 (Prepare for immediate surgical intervention): This directly contradicts the healthcare provider's prescription for conservative management. Surgical interventions like extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy are typically reserved for larger stones, those that fail to pass after a trial period, or cases with complications such as intractable pain, infection, or renal impairment [3, 4]. A 6mm stone has a reasonable chance of spontaneous passage, making a trial of conservative therapy appropriate.

Connecting to NCLEX-RN Client Needs

This question falls under the Physiological Integrity category, specifically Basic Care and Comfort and Reduction of Risk Potential. The nurse must understand the mechanism of action for non-pharmacological interventions. High-volume fluid intake is a foundational, evidence-based strategy to reduce the risk of stone recurrence and manage acute episodes by altering urine concentration and flow dynamics [2]. The nurse's role is to educate the client on this critical self-management strategy, explaining that the goal is to produce clear, dilute urine, which directly supports the physiological process of stone expulsion.References (research sources)

- [2]Improving compliance to serum calcium and urate testing guidelines for patients with renal stones: a Two-Cycle audit.GuidelineEnemoh O, Adefehinti M, Mvalo U, Iwunna O. (2025) · DOI: 10.51894/001c.143427

## 임상 시나리오

Clinical Practice Guidance: Conservative Management of Ureteral Calculus

For a client with a 6 mm calcium oxalate stone undergoing conservative management, the cornerstone of nursing care is to facilitate spontaneous stone passage while ensuring patient comfort and safety. The following evidence-based interventions should be prioritized:

- **Aggressive Hydration:** Instruct the client to increase oral fluid intake to achieve a urine output of at least 2.5 liters per day, typically requiring an intake of 3 to 4 liters daily. This high-volume diuresis increases hydrostatic pressure proximal to the stone, aiding propulsion, and dilutes lithogenic solutes to prevent stone growth.

- **Pain and Nausea Management:** Administer prescribed analgesics, often nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, and antiemetics promptly. Effective symptom control is essential to maintain the client's ability to tolerate oral hydration.

- **Urine Straining and Monitoring:** Provide a urine strainer and instruct the client to strain all voided urine to capture the stone for composition analysis. Document the passage of the stone, and monitor urine output and characteristics.

- **Activity and Positioning:** Encourage ambulation as tolerated. Gravity and movement can assist in the distal migration of the calculus through the ureter.

- **Patient Education:** Teach the client to recognize signs of complications requiring immediate medical attention, such as intractable pain, fever, chills, or anuria. Educate on dietary modifications to prevent recurrence once the acute episode resolves, including limiting sodium and animal protein intake.

Surgical or urological intervention is reserved for stones that fail to pass after an appropriate trial period, typically 4 to 6 weeks, or in the presence of complications such as obstruction, infection, or refractory pain.

## 핵심 개념

- **Conservative management** — A non-surgical approach for small kidney stones that focuses on hydration, pain control, and allowing the stone to pass spontaneously.
- **Calcium oxalate stone** — The most common type of kidney stone, formed when calcium combines with oxalate in concentrated urine.
- **Hydrostatic pressure** — The pressure exerted by a fluid at rest; in urolithiasis, increased urine volume raises pressure behind the stone to aid its propulsion through the ureter.
- **Hemodilution** — A decrease in the concentration of solutes in the blood or urine due to increased fluid volume, reducing the risk of crystal aggregation.

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