A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take?
a. Document the finding in the client's record.
b. Evaluate the tube as working in the hand-off report.
c. Clamp the tube in preparation for removing it.
d. Assess the client's abdomen and vital signs.
ANS: D
The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the client's abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate.
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