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: Impaired skin integrity is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and cortisol deficiency.
Choice B Reason: Fluid volume overload is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and aldosterone deficiency.
Choice C Reason: Imbalanced nutrition: more than body requirements is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and weight loss.
Choice D Reason: Risk for injury is the most appropriate nursing diagnosis for a client with Addison's disease, as it reflects the main problem of adrenal insufficiency and hypotension, which can cause falls, fainting, or shock.
Correct Answer is C
Explanation
Choice A Reason: Lantus is not a type of insulin that can treat this client, as it is a long-acting insulin that has no peak effect and lasts for 24 hours.
Choice B Reason: NPH is not a type of insulin that can treat this client, as it is an intermediate-acting insulin that peaks in 6 to 8 hours and lasts for 12 to 18 hours.
Choice C Reason: Regular is a type of insulin that can treat this client, as it is a short-acting insulin that peaks in 2 to 4 hours and lasts for 6 to 8 hours. It can be used to correct high blood glucose levels and treat diabetic ketoacidosis (DKA), which is indicated by confusion, flushing, and acetone breath.
Choice D Reason: Lispro is not a type of insulin that can treat this client, as it is a rapid-acting insulin that peaks in 30 minutes and lasts for 3 to 5 hours. It can be used to cover meals or snacks but not to treat DKA.
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