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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because anti-embolism stockings are designed to prevent swelling and blood clots in the legs by applying graduated compression, which is tighter around the ankle and looser as it moves up the leg. Applying the stockings in the morning before any swelling occurs ensures a proper fit and optimal blood flow.
Choice A is wrong because massaging the legs can dislodge a blood clot and cause a pulmonary embolism.
Choice C is wrong because wetting the stockings can make them harder to apply and reduce their effectiveness.
Choice D is wrong because removing the stockings before bathing can increase the risk of swelling and clotting, and applying fresh ones afterward can be difficult and uncomfortable.
Correct Answer is C
Explanation
This statement requires further follow-up because it indicates that the client may have poor sleep quality or quantity, which can affect their health and well-being. According to, the main components of the sleep history include defining the specific sleep problem, assessing the disorder’s clinical course, differentiating between sleep disorders, evaluating the sleep-wakefulness patterns, questioning the bed partner, and obtaining a family history of sleep disorders.
Choice A is wrong because falling asleep after about 15 minutes is normal and indicates good sleep hygiene.
Choice B is wrong because waking up to urinate once each night is not uncommon in older adults and does not necessarily disrupt their sleep continuity.
Choice D is wrong because having a regular nighttime routine is beneficial for promoting relaxation and preparing for sleep.
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