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 D
Explanation
Choice A Reason: Anorexia is not a symptom of hypoglycemia, but it may indicate a loss of appetite due to other causes such as nausea, infection, or depression.
Choice B Reason: Warm skin is not a symptom of hypoglycemia, but it may indicate a fever, inflammation, or infection.
Choice C Reason: Fruity breath is not a symptom of hypoglycemia, but it may indicate ketoacidosis, which is a serious complication of hyperglycemia.
Choice D Reason: Nervousness is a symptom of hypoglycemia, as the low blood glucose level affects the brain and causes anxiety, irritability, confusion, and tremors.
Correct Answer is D
Explanation
Choice A Reason: Calling the RN supervisor is not the priority action for the nurse, as it may delay the intervention and outcome.
Choice B Reason: Completing an incident report is not the priority action for the nurse, as it does not address the immediate problem or prevent further complications.
Choice C Reason: Checking the blood glucose level is not the priority action for the nurse, as it may confirm the error but not correct it.
Choice D Reason: Giving the client 15 to 20 g of carbohydrate is the priority action for the nurse, as it may prevent or treat hypoglycemia, which is a serious complication of insulin overdose.
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