Question

A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of the following findings should the nurse report to the provider?

a) Pink-tinged urine
b) Swelling at the insertion site
c) Absence of drainage in the collection bag
d) Mild discomfort during movement

Answer 1

The nurse should report the absence of drainage in the collection bag to the provider as it may indicate a serious complication like blockage or dislocation of the nephrostomy tube.

Step-by-step explanation:

The client with a nephrostomy tube inserted 112 hours ago is under close observation for any complications that may arise from the procedure. Among the listed findings, the one that should be reported to the provider immediately is c) Absence of drainage in the collection bag. This could indicate a blockage or dislocation of the nephrostomy tube, which could lead to kidney damage or infection if not addressed promptly. Mild discomfort during movement and pink-tinged urine can be normal soon after tube placement. Some swelling at the insertion site is expected, but if severe, it should also be reported. It is crucial to monitor the site for signs of infection, such as excessive redness, warmth, or pus, which were noted in the clinical focus examples provided.