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
Sensory deprivation is a condition in which a person experiences a lack of sensory input or stimulation.
This can result from isolation, confinement, or loss of sensory function. Sensory deprivation can cause psychological and physiological changes, such as irritability, confusion, paranoia, hallucinations, depression, anxiety, and cognitive impairment.
Choice A is wrong because mood disorder is a general term for a group of mental health conditions that affect a person’s emotional state, such as depression, bipolar disorder, or anxiety disorder. Mood disorder is not likely to be caused by isolation precautions for C diff.
Choice C is wrong because anxiety is a feeling of nervousness, worry, or fear that interferes with daily functioning. Anxiety can be triggered by stress, trauma, or other factors, but it is not a direct consequence of isolation precautions for C diff.
Choice D is wrong because cerebral vascular accident (CVA), also known as stroke, is a sudden interruption of blood flow to the brain that causes neurological damage. CVA can cause symptoms such as weakness, numbness, slurred speech, vision loss, or confusion, but it is not related to isolation precautions for C diff.
Correct Answer is B
Explanation
Gently pull the auricle up and back before instilling the drops. This technique straightens the auditory canal and allows the drops to reach the eardrum.
It also prevents contamination of the ear canal by the finger.
Choice A is wrong because pulling the auditory canal down and toward the front is the proper method for children, not adults.
This technique is used for children because their auditory canal is shorter and more curved than adults.
Choice C is wrong because lowering the head and taking a deep breath during the instillation has no effect on the administration of otic drops.
It may also cause discomfort or dizziness for the client.
Choice D is wrong because wearing sterile gloves and inserting one finger in the canal is unnecessary and potentially harmful.
It may introduce bacteria or damage the ear canal or eardrum.
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