The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?
Report when hematuria becomes pink tinged.
Restrict all physical activities.
Use the incentive spirometer.
Monitor urinary stream for decreased output.
The Correct Answer is D
A. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtaining a focused history to determine recent bleeding and use of anticoagulants is crucial to evaluate the risk of hemorrhage and guide treatment decisions, especially considering the symptoms suggest a possible stroke.
B. Initiating sequential pneumatic compression devices is not relevant to the immediate neurological symptoms.
C. Administering aspirin is contraindicated without confirming whether the stroke is ischemic or hemorrhagic.
D. Placing an indwelling urinary catheter is not an immediate priority compared to assessing the stroke symptoms.
Correct Answer is A
Explanation
A. The priority is to immediately intervene in the care being provided by the UAP and assess the client's condition to ensure prompt intervention if necessary.
B. While educating the UAP is important, immediate assessment and intervention for the client take precedence.
C. Investigating the reason for the UAP's actions can wait until after the client's condition has been assessed and stabilized.
D. Administering oral medications can wait until after the client's condition has been assessed and stabilized.
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