A patient has a nephrostomy tube that has been inserted because of an obstruction in the ureter. What special precautions in the care of the nephrostomy tube should the nurse implement?
Leaving the nephrostomy site open to air.
Instilling no more than 50 mL of sterile water if sterile irrigations are ordered.
Clamping every 2 hours to allow expansion of the kidney pelvis.
Being certain the tube is connected, not kinked, or not clamped to ensure that it continually drains.
The Correct Answer is D
A. Leaving the nephrostomy site open to air: The nephrostomy site should be covered with a sterile dressing to prevent infection.
B. Instilling no more than 50 mL of sterile water if sterile irrigations are ordered: Irrigation should be done with care, and no more than 5-10 mL of sterile solution is typically instilled to avoid kidney damage.
C. Clamping every 2 hours to allow expansion of the kidney pelvis: Clamping the nephrostomy tube is contraindicated as it can lead to increased pressure in the kidney, worsening the obstruction and potentially causing damage.
D. Being certain the tube is connected, not kinked, or not clamped to ensure that it continually drains: Ensuring the tube remains patent and continuously drains is essential to avoid complications such as hydronephrosis or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increases the appetite: Aluminum hydroxide does not have an appetite-stimulating effect.
B. Corrects the pH of the bowel: Aluminum hydroxide does not directly alter bowel pH; it is used to bind phosphate.
C. Calms the frequent upset stomach experienced by patients on dialysis: Although aluminum hydroxide can reduce stomach acid, its primary use in this context is as a phosphate binder.
D. Binds with phosphorus to increase the serum calcium level: Aluminum hydroxide binds dietary phosphorus in the gastrointestinal tract, reducing serum phosphorus levels. This helps manage the calcium-phosphorus balance, preventing complications like bone demineralization.
Correct Answer is B
Explanation
A. Eliminate urinary retention: Urinary antimicrobials do not address retention; this would require medications that promote bladder emptying.
B. Have an antiseptic effect on the urine and the urinary tract: Urinary antimicrobials work by reducing bacterial growth within the urinary tract.
C. Enhance output enough to flush out the infection from the urinary tract: Increased output may help prevent infections, but antimicrobials target bacterial pathogens directly.
D. Reduce pain associated with bladder spasms caused by the infection: Analgesics, not antimicrobials, are used for pain relief.
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