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 D
Explanation
Use a fresh washcloth when cleaning each eye. This is because using the same washcloth for both eyes can transfer microorganisms from one eye to the other and cause cross-infection.
The other choices are wrong because:
Choice A is wrong because wiping from the outer part of the eye toward the inner portion can introduce microorganisms into the tear ducts and cause infection.
Choice B is wrong because rinsing the washcloth before washing the second eye does not eliminate all the microorganisms that might be on the cloth.
Choice C is wrong because asking the client to roll the eyes upward does not prevent spreading organisms from one eye to the other when bathing a client.
Normal ranges for eye hygiene are to use a clean washcloth or cotton ball for each eye, wipe from the inner to the outer canthus, and use warm water or saline solution.
Correct Answer is C
Explanation
This is because spinach and salads contain a lot of vitamin K, which can make warfarin less effective at preventing blood clots.
Vitamin K helps the blood to clot, so eating foods high in vitamin K can counteract the effect of warfarin.
Choice A is wrong because wheat bread and butter do not contain a lot of vitamin K and do not affect warfarin.
Choice B is wrong because mangoes and tomatoes do not contain a lot of vitamin K and do not affect warfarin.
Choice D is wrong because aged cheeses and wine do not contain a lot of vitamin K and do not affect warfarin.
It is important to keep a stable diet while taking warfarin and avoid sudden changes in the amount of vitamin K intake. Foods that are high in vitamin K include green leafy vegetables, chickpeas, liver, egg yolks, avocado, and olive oil.
These foods should be limited but not eliminated from the diet. Do not drink cranberry or grapefruit juice while taking warfarin as they can increase the risk of bleeding.
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