Which health care provider prescription for a client with a nephrostomy tube should a nurse question?
Monitor the urine’s color and odor.
Record the intake and output every eight hours.
Irrigate the tube with 30 mL of sterile saline as needed.
Measure the vital signs every four hours during the day.
The Correct Answer is C
Irrigating the tube with 30 mL of sterile saline as needed. This prescription should be questioned by the nurse because it may cause trauma to the kidney or dislodge the tube. The nurse should only irrigate the tube if ordered by the health care provider and with a smaller amount of fluid.
Choice A is wrong because monitoring the urine’s color and odor is an appropriate intervention for a client with a nephrostomy tube. The urine may be bloody or cloudy initially, but it should gradually clear.
Choice B is wrong because recording the intake and output every eight hours is also an appropriate intervention for a client with a nephrostomy tube. The nurse should measure and document the amount and characteristics of urine drainage and report any changes or abnormalities.
Choice D is wrong because measuring the vital signs every four hours during the day is a reasonable prescription for a client with a nephrostomy tube. The nurse should monitor the client for signs of infection, bleeding, or obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client on Digitalis has a low potassium level of 3.0 mEq/L, below the normal range of 3.5-5.0 mEq/L. Low potassium levels can increase the risk of digitalis toxicity, which can cause nausea, abdominal discomfort, visual changes, and cardiac arrhythmias.
The nurse would instruct the client to eat foods high in potassium, such as cantaloupe, to prevent or correct hypokalemia.
Choice A. Asparagus is wrong because asparagus is a low-potassium food that contains only 202 mg of potassium per cup.
Eating asparagus would not help to raise the client’s potassium level.
Choice C. Blackberries are wrong because blackberries are also a low-potassium food that contains only 233 mg of potassium per cup.
Eating blackberries would not help to raise the client’s potassium level.
Choice D. Cucumbers is wrong because cucumbers are a very low-potassium food that contains only 76 mg of potassium per cup.
Eating cucumbers would not help to raise the client’s potassium level and may even lower it further.
Correct Answer is ["A","B","C","D"]
Explanation
The correct answers are Choices A, B, C, and D.Choice A rationale:Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale:Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale:Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale:Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale:Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today