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 ["A","B"]

Explanation

Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.

Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.

Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.

Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.

Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:

Heart rate: 60 to 100 beats per minute for adults
Blood pressure: less than 120/80 mmHg for adults

A. “I don’t know.Biopsies are often negative.”. B. “I can’t say. Did your health care provider tell you?”. C. “No one knows yet. I’d like to hear what you are thinking.”. D. “Everyone thinks about that. Don’t worry until the final report is back.”.

Correct Answer is C

Explanation

I’d like to hear what you are thinking.” This response by the nurse would most likely prompt the client to elaborate on their concerns because it acknowledges the uncertainty of the situation and invites the client to share their feelings and thoughts.

It also shows empathy and respect for the client’s perspective.

Choice A is wrong because it may give false reassurance or minimize the client’s anxiety. Biopsies are not always negative and the nurse cannot predict the outcome.

Choice B is wrong because it may imply that the nurse is avoiding the question or shifting the responsibility to the health care provider.

It also does not address the client’s emotional state or encourage communication.

Choice D is wrong because it may dismiss the client’s fears or imply that they are irrational. It also does not explore the client’s understanding of the procedure or the possible results.

A uterine biopsy is a procedure that involves removing a small piece of tissue from the lining of the uterus (endometrium) for examination under a microscope. It is usually done to diagnose abnormal bleeding, infections, or cancer. The normal range of endometrial thickness varies depending on the menstrual cycle, age, and hormonal status of the woman.

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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

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.

Correct Answer is ["A","B"]

Explanation

Following a uterine biopsy, a client asks a nurse, “Do you think I have cancer?” Which response by the nurse would most likely prompt the client to elaborate on their concerns?

Correct Answer is C

Explanation

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