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 A
Explanation
“Have you had thoughts about killing yourself?” This is the best response because it directly assesses the client’s suicidal risk and shows empathy and concern.
The other choices are wrong because:
Choice B. “What can’t you go on anymore?” This is a vague and open-ended question that does not address the client’s immediate safety or emotional state.
Choice C. “Don’t think like that.
It’s not true!” This is a dismissive and invalidating response that does not acknowledge the client’s feelings or offer support.
Choice D. “Have you talked to your doctor about these feelings?” This is a deferring and avoiding response that does not explore the client’s situation or provide any intervention.
Correct Answer is C
Explanation
The proper length of the needle to administer a subcutaneous injection depends on the amount of adipose tissue over the muscle.
The needle should be long enough to reach the subcutaneous layer but not so long that it penetrates the muscle. The needle gauge and length vary depending on the patient’s size and the injection site
Choice A is wrong because the age of the client does not determine the needle length.
However, age may affect the amount of adipose tissue and muscle mass, which are factors to consider when choosing a needle length.
Choice B is wrong because the viscosity of the solution does not determine the needle length. However, viscosity may affect the needle gauge, which is the diameter of the needle.
Thicker solutions may require larger gauge needles to allow easier flow.
Choice D is wrong because the quantity of the solution does not determine the needle length.
However, quantity may affect the syringe size, which is the volume of medication that can be held by the syringe.
The syringe size should match the prescribed dose as closely as possible to ensure accuracy and ease of measurement.
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