A nurse is caring for a client who had a cholecystectomy and has a T-tube drain. Which of the following actions should the nurse take?
Apply a transparent dressing to the drain site.
Clamp the tubing when the client ambulates.
Place the client into Fowler's position.
Secure the tubing to the client's gown.
The Correct Answer is C
Choice A Reason: Applying a transparent dressing to the drain site is not an appropriate action for the nurse to take, as it may trap moisture and bacteria and increase infection risk.
Choice B Reason: Clamping the tubing when the client ambulates is not an appropriate action for the nurse to take, as it may cause bile accumulation and leakage and increase pressure and pain.
Choice C Reason: Placing the client into Fowler's position is an appropriate action for the nurse to take, as it helps to promote drainage and prevent reflux of bile into the liver.
Choice D Reason: Securing the tubing to the client's gown is not an appropriate action for the nurse to take, as it may cause tension and displacement of the drain and increase discomfort and bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Determining the client's calcium level is the appropriate action for the nurse to take, as it may indicate hypocalcemia, which is a possible complication of thyroidectomy due to accidental removal or damage of the parathyroid glands. Hypocalcemia can cause muscle spasms, tingling, numbness, or tetany.
Choice B Reason: Monitoring the client's peripheral pulses is not the appropriate action for the nurse to take, as it does not address the cause of muscle spasms or provide any relief.
Choice C Reason: Administering IV normal saline solution is not the appropriate action for the nurse to take, as it does not correct hypocalcemia or prevent further complications.
Choice D Reason: Giving the client an oral potassium supplement is not the appropriate action for the nurse to take, as it may worsen hypocalcemia or cause hyperkalemia, which can affect cardiac function and muscle contraction.
Correct Answer is C
Explanation
Choice A Reason: Assisting the RN to prepare an IV insulin infusion is not the first action that the nurse should take, as it may not be appropriate for the client's condition without knowing the blood glucose level.
Choice B Reason: Giving the client 4 oz of orange juice is not the first action that the nurse should take, as it may worsen the client's condition if the blood glucose level is high.
Choice C Reason: Checking the client's capillary blood glucose is the first action that the nurse should take, as it helps to determine if the client has hyperglycemia or hypoglycemia and guides the appropriate intervention.
Choice D Reason: Assisting the RN to administer 50% dextrose is not the first action that the nurse should take, as it may be harmful for the client if the blood glucose level is high.
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