After 6 hours of nephrostomy, the patient complains of nausea and abdominal distention. What should the nurse… - AIIMS Rishikesh NO - 2019

AIIMS Rishikesh NO - 2019

Medical Surgical Nursing

Hard

Appeared in: AIIMS Rishikesh NO - 2019

Explanation

The patient's symptoms of nausea and abdominal distention after a nephrostomy strongly suggest a blockage or dislodgement of the tube.
The priority nursing action is to assess the function of the device by checking for adequate urine output.
A lack of drainage is a critical finding that indicates an obstruction, which can lead to hydronephrosis (swelling of the kidney) and irreversible kidney damage.
Based on the assessment of urine output, the nurse must immediately inform the on-duty doctor to facilitate prompt diagnosis and intervention.

Option B: While checking temperature is important to monitor for infection, the patient's symptoms of nausea and distention are more indicative of a mechanical obstruction rather than an infection at this early stage.
Option C: Checking blood pressure is a routine assessment, but it does not directly address the cause of nausea and abdominal distention in this context. These symptoms are not primary signs of hemorrhage or hypotension.
Option D: Assessing the level of consciousness (LOC) is a fundamental part of nursing care, but a change in LOC would be a late sign of a severe complication like advanced sepsis. The patient's symptoms point to a more localized, acute problem.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Post-procedural complications of nephrostomy and priority nursing interventions in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Prompt identification of nephrostomy tube obstruction is critical for preventing permanent kidney damage. A nurse's vigilant monitoring of urine output is the first line of defense.
Any significant decrease in drainage or new onset of flank pain, nausea, or fever in a patient with a nephrostomy tube must be treated as a potential emergency and escalated immediately.
What if the patient also complained of severe, acute flank pain on the side of the nephrostomy? This would make the suspicion of an obstruction even higher, and the nurse's action to check output and notify the physician would be even more urgent.

How to Approach the Question

First, identify the key elements of the clinical scenario: a patient who is 6 hours post-procedure (nephrostomy) is developing new symptoms (nausea, abdominal distention).
Consider the purpose of the procedure. A nephrostomy tube is placed to drain urine from the kidney.
Relate the new symptoms to the function of the device. Nausea and distention can be caused by pressure from fluid that is not draining properly.
Evaluate the options based on priority. The most immediate and life-threatening problem for this patient is a blocked tube leading to kidney damage.
Select the intervention that directly assesses and addresses the most likely cause. Checking urine output directly assesses the tube's patency, which is the primary concern.

Concept Tested & Keywords

Concept Tested: Post-procedural complications of nephrostomy and priority nursing interventions.
Stem keywords: nephrostomy, nausea, abdominal distention, 6 hours
Lead-in keywords: intervene
Clinical cues: The patient's symptoms (nausea, abdominal distention) are classic signs of a blockage or leakage from a urinary drainage tube.

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E6 Nursing Fundamentals Taylor pp. 605-607, 606-608