A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?

A nephrostomy tube to a drainage bag

An NG tube to suction

An indwelling urinary catheter to gravity drainage

A chest tube to water-seal drainage

Answer and Explanation

The Correct Answer is B

A. A nephrostomy tube to a drainage bag:
A nephrostomy tube drains urine from the kidney to a drainage bag. While it's essential for urinary drainage, it doesn't lead to significant potassium loss, as potassium is primarily excreted through the urine.

B. An NG tube to suction:
An NG tube (Nasogastric tube) is inserted through the nose into the stomach. When connected to suction, it can remove stomach contents, including gastric acid and potassium. Excessive suctioning can lead to significant potassium loss, potentially causing hypokalemia.

C. An indwelling urinary catheter to gravity drainage:
An indwelling urinary catheter drains urine from the bladder into a drainage bag by gravity. While potassium can be found in urine, the drainage through a catheter does not cause significant potassium loss unless there are underlying kidney issues, which are not specified in this scenario.

D. A chest tube to water-seal drainage:
A chest tube removes air or fluid from the pleural space around the lungs. While chest tubes are vital for lung expansion, they don't result in significant potassium loss as they are not connected to body fluids rich in potassium, like gastric acid or urine.

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Correct Answer is B

Explanation

A. Slight bleeding of the stoma site: This is typically normal in the immediate postoperative period. It's caused by surgical trauma and should improve with time. However, if it becomes excessive, it should be reported.

B. Purplish colored stoma: A purplish or bluish color of the stoma can be an indication of inadequate blood supply (ischemia). This is a concerning finding and should be reported promptly to the provider.

C. No stool noted in the collection bag: It's normal not to have stool in the collection bag immediately after surgery since the digestive system needs time to resume normal function. This is usually not a concern within the first 12 hours postoperatively. However, if it continues beyond this time frame, it should be reported.

D. Edematous stoma: Some edema or swelling around the stoma site can be normal initially after surgery. However, if the stoma becomes significantly edematous or starts to compromise blood flow, this should be reported to the provider.

A. Obtain the client's vital signs. B. Weigh the client. C. Change the client's dressing. D. Administer pain medication.

Correct Answer is D

Explanation

A. Obtain the client's vital signs:
Vital signs are essential for assessing the client's overall condition and can provide crucial information about the client's stability. However, in this scenario, there's a higher priority nursing action that needs immediate attention.

B. Weigh the client:
Daily weight measurement is important, especially in postoperative patients, to monitor for fluid retention or loss. However, this is not the most urgent action in this situation.

C. Change the client's dressing:
Changing the dressing involves maintaining the surgical site's cleanliness and preventing infections. While this is important, it's not the highest priority in this situation.

D. Administer pain medication:
Correct Choice. Addressing the client's pain is a priority to ensure their comfort and well-being, especially postoperatively. Managing pain effectively is crucial for the client's recovery and can facilitate other necessary activities, such as changing the dressing or weighing the client.

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A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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