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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The nurse should respect the client’s privacy and confidentiality by not discussing the client’s condition in a crowded elevator, even with the health care provider. The nurse should suggest a more private area to have the conversation.

Choice A is wrong because it shows a lack of professionalism and accountability. The nurse should be able to provide a brief update on the client’s status to the health care provider, even if the nurse is off duty.

Choice B is wrong because it implies that the healthcare provider does not have the right to access the client’s information, which is not true. The health care provider is part of the health care team and has a legitimate need to know the client’s condition.

Choice D is wrong because it violates the client’s privacy and confidentiality by disclosing sensitive information in front of other people. The nurse should not share any details about the client’s condition or treatment without the client’s consent or unless it is necessary for the client’s care.

A. Rhonchi. B. Wheezing. C. Crackles. D. Pleural friction rub.

Correct Answer is A

Explanation

Rhonchi. Rhonchi are low-pitched, rattling sounds that indicate mucus in the larger airways. They are most evident on expiration and may decrease after coughing.

Choice B is wrong because wheezes are high-pitched, squeaking sounds that indicate narrowed small air passages. They are usually heard on both inspiration and expiration.

Choice C is wrong because crackles are short, high-pitched popping sounds that indicate fluid or inflammation in the alveoli. They are usually heard on inspiration.

Choice D is wrong because pleural friction rubs are creaking or grating sounds that indicate inflammation of the pleura. They are usually heard on both inspiration and expiration and do not change with coughing.

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Which health care provider prescription for a client with a nephrostomy tube should a nurse question?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

At the end of the shift, a nurse enters a crowded elevator and is standing near a client’s health care provider. Which response of the nurse is most appropriate when the health care provider asks, “How is my client in room 913 doing?”.

Correct Answer is C

Explanation

A nurse assessing a client’s lung sounds hears continuous low-pitched harsh rattling sounds over the client’s trachea that are most evident on expiration and are decreased after coughing. Which term is the appropriate choice to accurately document this lung sound?

Correct Answer is A

Explanation

The health care provider orders a trough level of an antibiotic administered every twenty four hours. When should the nurse plan for a trough level to be drawn?

Your client has anaphylaxis listed as a penicillin allergy. Which antibiotic would be safe for your client to receive?

When a nurse respects the decision of a client who refuses a blood transfusion, which ethical principle is the nurse upholding?

A 68-year-old client diagnosed with cataracts should be assessed for which finding?

What does the nurse know to be the goals of client teaching? (Select all that apply).

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Which measure should a nurse include in the care plan for a client who has mitt restraints to prevent pulling out tubes?

A client asks a nurse, “Why do I have to remove my nail polish in order for my pulse oximetry to be monitored?” Which is the best response by the nurse?