Question

During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:

Assess the drainage bag.
Check for bladder distention.
Unclamp the tubing.
Irrigate the tubing.

Answer 1

The nurse's first action upon finding a clamped nephrostomy tube is to unclamp it to restore drainage and prevent kidney damage. Further assessments of the drainage bag and for bladder distention should follow this immediate unclamping.

Step-by-step explanation:

The question pertains to the appropriate nursing action when a nephorostomy tube has been found clamped during a morning assessment. Given the serious implications of an obstructed nephrostomy tube, the nurse's first action should be to unclamp the tubing. This immediate action is necessary to restore drainage and prevent complications such as infection, leakage, or backflow that could harm the kidney. After unclamping, the nurse should then assess the drainage bag, check for bladder distention, and ensure there are no other issues that could compromise the patient's recovery or the integrity of the nephrostomy system. In cases like these, where a patient has undergone a procedure, the healthcare team typically reviews the items aloud including confirming the procedure name, needle, sponge, and instrument counts, specimen labeling, and equipment functionality. Furthermore, nurses providing dialysis treatments under the direct supervision of a registered nurse will also conduct thorough patient assessments, respond to needs, and monitor procedures, applying the same principles of attention to detail and patient care.