A client undergoes a nephrectomy. In the immediate postoperative period, which nursing intervention has the highest priority?
1. Monitoring blood pressure.
2. Encouraging the use of the incentive spirometer.
3. Assessing urine output hourly.
4. Checking the flank dressing for urine drainage.
After a nephrectomy, a specific aspect of immediate postoperative management includes monitoring urine output at least hourly.
Monitoring blood pressure and encouraging the use of incentive spirometry are other important considerations, but because of the surgical disruption of the urinary system, urine output is a priority.
Measurement of urine output should also include an estimation of the amount of urine drainage on the flank dressing.
CN: Reduction of risk potential; CL: Synthesize