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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason: High glucose level is not a finding that confirms bacterial meningitis, but it may indicate other conditions such as diabetes mellitus or hyperglycemia.

Choice B Reason: Low protein concentration is not a finding that confirms bacterial meningitis, but it may indicate other conditions such as malnutrition or liver disease.

Choice C Reason: Decreased CSF pressure is not a finding that confirms bacterial meningitis, but it may indicate other conditions such as dehydration or spinal cord injury.

Choice D Reason: Cloudy CSF is a finding that confirms bacterial meningitis, as it indicates that there is an infection and inflammation in the meninges that surround the brain and spinal cord.

A. Checks blood sugar then eats breakfast prior to injecting insulin. B. Rotates sites from arms, legs, and abdomen. C. Ensures the use of insulin syringe with units. D. Activates the safety lock on the syringe before disposing in a sharps container.

Correct Answer is A

Explanation

Choice A Reason: Checking blood sugar then eating breakfast prior to injecting insulin indicates that additional teaching is necessary, as it may cause hyperglycemia or hypoglycemia depending on the type and timing of insulin. The client should inject insulin before eating breakfast according to their blood sugar level and carbohydrate intake.

Choice B Reason: Rotating sites from arms, legs, and abdomen indicates that no additional teaching is necessary, as it helps to prevent lipodystrophy and ensure consistent absorption of insulin.

Choice C Reason: Ensuring the use of insulin syringe with units indicates that no additional teaching is necessary, as it helps to prevent dosing errors and ensure accurate administration of insulin.

Choice D Reason: Activating the safety lock on the syringe before disposing in a sharps container indicates that no additional teaching is necessary, as it helps to prevent needlestick injuries and infection transmission.

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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?

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Naxlex Comprehensive Predictor Exams

A lumbar puncture is performed on a client with suspected bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse determines that the diagnosis is confirmed if which findings are noted?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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