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. Irritability and hyperactivity: Glomerulonephritis does not directly cause these symptoms; neurological changes are more associated with uremia in advanced kidney disease.
B. Low blood volume with polyuria: Glomerulonephritis often leads to fluid retention rather than polyuria, resulting in increased blood pressure.
C. Low levels of BUN and creatinine: BUN and creatinine levels are typically elevated due to impaired filtration.
D. Moderate to high blood pressure: The inflammatory process in glomerulonephritis often leads to fluid retention and hypertension.
Correct Answer is A
Explanation
A. “It is a normal postoperative expectation.” Hematuria is common immediately after renal transplantation due to surgical trauma and typically resolves as healing occurs.
B. “It is related to the immunosuppressant drugs taken before transplantation.” Immunosuppressant drugs do not cause hematuria directly.
C. “It is caused by dye injected during surgery.” Dye is not routinely used in renal transplantation, and hematuria would not be related to this.
D. “It is caused by a small vessel that may be bleeding but will coagulate as urine flow increases.” While small vessel bleeding can occur, it is better to explain the hematuria as a normal postoperative expectation.
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