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 A
Explanation
Choice A Reason: Managing diarrhea is the priority goal for the client's care, as it helps to prevent dehydration, electrolyte imbalance, malnutrition, and infection.
Choice B Reason: Promoting rest and comfort is an important goal for the client's care, but it is not the priority, as it does not address the underlying cause of the exacerbation.
Choice C Reason: Increasing self-esteem is a long-term goal for the client's care, but it is not the priority, as it does not affect the physical condition of the client.
Choice D Reason: Promoting self-care and independence is a long-term goal for the client's care, but it is not the priority, as it does not affect the acute symptoms of the exacerbation.
Correct Answer is B
Explanation
Choice A Reason: The procedure will not be cancelled if the urinalysis indicates the presence of red blood cells, but it may indicate a urinary tract infection or kidney damage that needs further evaluation.
Choice B Reason: After the procedure, you will be encouraged to drink plenty of fluids, as this helps to flush out the contrast dye that was injected into your vein and prevent dehydration and kidney damage.
Choice C Reason: High frequency sound waves will not be used to identify renal system structures, but this is the principle of ultrasound imaging, which is a different diagnostic test.
Choice D Reason: You will not need to remain flat in bed for 4 hours following this procedure, but you may need to rest for a short period of time and avoid strenuous activities for the rest of the day.
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