The nurse is caring for a client who had a cystoscopy in the day. Which symptom from the client is of most concern to the nurse?

Appeared in: UPUMS Nsg.Officer-2024

Explanation

A complaint of back or flank pain after a cystoscopy is a significant red flag that requires immediate nursing attention.
This symptom can indicate a severe complication, such as a perforation of the bladder or ureter, leading to retroperitoneal bleeding or fluid leakage.
Back pain can also be a classic sign of an ascending urinary tract infection that has progressed to the kidneys, a condition known as pyelonephritis.
Both perforation and pyelonephritis are serious conditions that can lead to sepsis or permanent kidney damage if not treated promptly.

Option A: Leg cramps are generally a benign and temporary side effect related to the lithotomy position used during the cystoscopy procedure, not a complication of the procedure itself.
Option B: Tea-colored urine indicates the presence of old blood. While it requires monitoring, it is less concerning than bright red blood (indicating active bleeding) or symptoms of infection/perforation.
Option D: Pink-tinged urine is an expected and common finding after a cystoscopy. It is caused by minor trauma to the urethral and bladder mucosa from the scope.

Clinical Relevance

Nursing practice connection: Use the key finding related to Post-procedure complications of cystoscopy to guide bedside assessment, documentation, and the next nursing action.
A key nursing responsibility in post-procedural care is to differentiate between expected, benign side effects and the signs of serious complications.
Prompt recognition and reporting of red flag symptoms like back pain after a cystoscopy can prevent progression to more severe conditions like sepsis or renal failure.
Patient education is crucial. Before discharge, the nurse must instruct the client to report fever, chills, inability to urinate, or severe pain immediately.

How to Approach the Question

First, identify the core of the question: it's asking for the most concerning symptom, which means you need to prioritize.
Review the procedure mentioned: cystoscopy. Recall the anatomy involved (urethra, bladder, ureters, kidneys) and the potential risks (infection, bleeding, perforation).
Categorize each option as either an 'expected finding' or a 'potential complication'.
Pink-tinged urine and mild discomfort are expected. Leg cramps are a positional side effect.
Evaluate the remaining options based on severity. Back pain can signal a complication involving the upper urinary tract (kidneys) or perforation, which is more life-threatening than the other options.
Select the symptom that points to the most severe potential complication as the correct answer.

Concept Tested & Keywords

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 1 pp. 136-138, 131-133

E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 17-19

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