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: Cushing's is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excess cortisol and aldosterone production.
Choice B Reason: Diabetes insipidus is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive water loss and dilution of blood.
Choice C Reason: Addison's is an expected health problem in a client with high potassium level, as it causes high potassium level due to insufficient cortisol and aldosterone production.
Choice D Reason: Diarrhea is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive fluid and electrolyte loss.
Correct Answer is B
Explanation
Choice A Reason: The presence of edema in the external auditory canal is not a sign of cerumen impaction, but it may indicate other conditions such as otitis externa or allergic reaction.
Choice B Reason: A yellowish or brownish waxy material in the external auditory canal is a sign of cerumen impaction, as it shows that there is excess or hardened earwax that blocks the ear canal.
Choice C Reason: Redness and swelling of the tympanic membrane are not signs of cerumen impaction, but they may indicate other conditions such as otitis media or trauma.
Choice D Reason: An external auditory canal that is longer than normal is not a sign of cerumen impaction, but it may be a normal variation or a result of aging.
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