Nokea
A nephrostomy tube is inserted in a client with a large ureteral calculus. Which is the most important consideration in providing nursing care for this client?
- A. Clamp the tube for no longer than 2 hours at a time.
- B. Maintain free, continuous urine drainage.
- C. Leave nephrostomy site open to the air.
- D. Use only sterile NSS to irrigate the tube.
Correct Answer: B
Rationale: Clamping or kinking of the tube will create backup of urine into the renal pelvis, resulting in hydronephrosis and can contribute to renal damage. Always make sure the urine is allowed to flow continuously and freely and do not irrigate. The nephrostomy tube is inserted through a stab wound and enters the kidney. A sterile dressing should be used to prevent pathogen entry.
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The nurse evaluates the client as experiencing symptoms of disequilibrium syndrome, following an initial hemodialysis treatment. Which is the appropriate action to be taken by the nurse?
- A. No action is needed.
- B. Hold the next scheduled treatment.
- C. Slow the dialysis process during future treatment.
- D. Notify the physician and manage the symptoms.
Correct Answer: C
Rationale: Disequilibrium syndrome is a neurologic condition believed to be caused by cerebral edema associated with rapid movement of water. The symptoms are self-limiting and disappear within several hours after dialysis but can be prevented by slowing the dialysis process to allow time for gradual equilibrium of water. The nurse should document the symptoms and notify the physician with repeated incidence.
The nurse is providing education to a client with acute glomerulonephritis. What should the nurse include in the teaching? Select all that apply.
- A. Identify high-sodium foods to include in the diet to increase dietary sodium.
- B. Explain the purpose of diuretic therapy or other prescribed medications, the dosing regimen, and side effects.
- C. Recommend regular blood pressure monitoring.
- D. Caution the client to avoid contact with persons who have infections.
- E. Advise the client that weight gain is an expected outcome.
Correct Answer: B,C,D
Rationale: The nurse should explain the purpose of diuretic therapy or other prescribed medications, the dosing regimen, and side effects, recommend regular blood pressure monitoring, and caution the client to avoid contact with persons who have infections. The nurse should identify the specific amount of sodium that the client is allowed and identify sources of sodium to avoid. The nurse should also advise the client to contact the primary provider if urinary volumes diminish, or if headaches, nosebleeds, or unexpected weight gain occur.
The nurse is caring for a client who has undergone a nephrectomy. Which assessment finding is most important in determining nursing care for the client?
- A. Urine output of 35 to 40 ml/hour
- B. Pain of 3 out of 10, 1 hour after analgesic administration
- C. SpO2 at 90% with fine crackles in the lung bases
- D. Blood tinged drainage in Jackson-Pratt drainage tube
Correct Answer: C
Rationale: Altered Breathing Pattern and Ineffective Airway Clearance Risk are often a challenge in caring for clients postnephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sounds. Intake and output are monitored to maintain a urine output of greater than 30 ml/hour. Pain control is important and should allow for movement, deep breathing, and rest. Blood-tinged drainage from the JP tube is expected in the initial postoperative period.
A client is administered dialystate solution through an abdominal catheter. The nurse notices that the return flow rate is slow, so the nurse advises the client to move to the other side. However, even after changing the client's position, the nurse does not observe an increase in return flow. Which of the following actions should the nurse perform to help accelerate the return flow rate?
- A. Disconnect the catheter and repay.
- B. Loosen the tubing clamp.
- C. Inform the physician that catheter may need repositioning.
- D. Stop the process for 5 minutes and resume later.
Correct Answer: C
Rationale: The nurse instills dialystate solution and clamps the tubing. If the return flow rate is slow, the nurse asks the client to move from side to side. If this maneuver is unsuccessful, the physician may need to reposition the catheter. The nurse should not tamper with the catheter settings because this may worsen the client's condition or damage the apparatus. Also, stopping the process and resuming it after 5 minutes will not help increase the return flow of the dialystate.
A client has a decreased secretion of erythropoietin from the kidneys due to end-stage kidney disease. The nurse explains that the decrease in erythropoietin will have what effect?
- A. Aemia from the decrease in maturation of red blood cells
- B. Decrease in blood sugar levels due to alteration in insulin levels
- C. Increase in blood sugar levels due to alteration in insulin levels
- D. Development of male sex characteristics
Correct Answer: A
Rationale: The kidneys secrete erythropoietin, which is a substance that promotes the maturation of red blood cells.