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 C
Explanation
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.
Correct Answer is D
Explanation
Choice A Reason: Side lying on the affected eye is not the correct position for the client after cataract surgery, as it may increase intraocular pressure and cause bleeding or damage to the surgical site.
Choice B Reason: Supine is not the correct position for the client after cataract surgery, as it may cause fluid accumulation and swelling in the eye.
Choice C Reason: Prone is not the correct position for the client after cataract surgery, as it may cause pressure and friction on the eye.
Choice D Reason: Semi Fowler's is the correct position for the client after cataract surgery, as it helps to reduce intraocular pressure and promote drainage and healing of the eye.
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