The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?
Report when hematuria becomes pink tinged.
Restrict all physical activities.
Use the incentive spirometer.
Monitor urinary stream for decreased output.
The Correct Answer is D
A. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While it's important to know about peripheral pulses and mobility, this is not as critical immediately post-op.
B. A history of vomiting is relevant but not immediately actionable for the current post-op care.
C. Dry mouth is a common and manageable symptom post-op, but not immediately critical.
D. A soft abdomen, absent bowel sounds, and no bleeding on dressing provide essential information on the client's current post-op status and potential complications, making it the most important information to confirm.
Correct Answer is B
Explanation
A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.
B.Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.
C.Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.
D.Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.
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