A patient is recovering from a common bile duct exploration and has a T-tube drain in place. As the nurse, which action is most appropriate to ensure proper function and patient safety?

Flush the T-tube with sterile water every 6 hours to maintain patency.

Clamp the T-tube for 12 hours each day to reduce bile flow

Secure the T-tube to the patient's gown to prevent accidental dislodgement.

Maintain the drainage bag below the level of the abdomen to promote gravity drainage.

Answer and Explanation

The Correct Answer is D

A. Flush the T-tube with sterile water every 6 hours to maintain patency: T-tubes are generally not flushed unless prescribed by a healthcare provider because flushing can introduce bacteria and cause complications. Patency is typically maintained by gravity drainage alone.

B. Clamp the T-tube for 12 hours each day to reduce bile flow: Clamping the T-tube is not routinely recommended for such long periods unless directed by the healthcare provider. Clamping is usually done gradually, often for 1-2 hours, to assess the patient’s ability to tolerate bile drainage naturally before tube removal.

C. Secure the T-tube to the patient's gown to prevent accidental dislodgement: While securing the T-tube prevents accidental dislodgement, the tube should be taped to the skin rather than the gown, as attaching it to clothing can increase the risk of unintentional dislodgement with movement.

D. Maintain the drainage bag below the level of the abdomen to promote gravity drainage. This is the correct answer because positioning the drainage bag below the abdomen allows for gravity to assist in the flow of bile from the bile duct, preventing backup and promoting proper drainage.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","F"]

Explanation

A. Increased fluid intake and patient education on hydration: Encouraging increased fluid intake helps to flush bacteria from the urinary tract and prevent further infection. Hydration is a key component of managing UTIs, as it dilutes urine and promotes frequent urination, reducing bacterial colonization.

B. Blood cultures: Blood cultures are not typically indicated for uncomplicated UTIs, especially in a patient without signs of systemic infection or sepsis (e.g., high fever, hypotension, tachycardia). Blood cultures are more relevant in severe or complicated UTIs, or when there is concern for urosepsis.

C. Urine culture and sensitivity testing: A urine culture and sensitivity is essential for identifying the specific bacteria causing the infection and determining the appropriate antibiotic for treatment. This is especially important for patients with a history of recurrent UTIs to ensure the right antibiotic is selected and to avoid antibiotic resistance.

D. Repeat urinalysis after antibiotic treatment completion: A repeat urinalysis after antibiotic treatment is often ordered to ensure that the infection has been resolved, particularly in patients with recurrent infections.

E. Foley catheter placement: A Foley catheter is not appropriate for this patient, as there is no indication of urinary retention, and catheterization increases the risk of introducing new infections.

F. Oral antibiotics, such as trimethoprim-sulfamethoxazole or ciprofloxacin: Oral antibiotics like trimethoprim-sulfamethoxazole (TMP-SMX) or ciprofloxacin are commonly prescribed for treating uncomplicated UTIs. Given the patient’s history of recurrent UTIs, empiric antibiotic therapy is appropriate pending urine culture results.

A. Measure abdominal girth daily. B. Moisten the client's lips with lemon-glycerin swabs. C. Maintain the client in Fowler's position. D. Use sterile water to irrigate the nasogastric tube.

Correct Answer is A

Explanation

A. Measure abdominal girth daily. Measuring abdominal girth daily helps assess for changes in distention, which is important in monitoring the effectiveness of the decompression.

B. Moisten the client's lips with lemon-glycerin swabs: This is incorrect because lemon-glycerin swabs can dry the oral mucosa. Using plain water or normal saline swabs would be more appropriate.

C. Maintain the client in Fowler's position: This is appropriate as it helps promote drainage from the nasogastric tube and reduces the risk of aspiration.

D. Use sterile water to irrigate the nasogastric tube: Irrigation is typically done with normal saline to maintain electrolyte balance. Sterile water is not recommended for this purpose.

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A patient is recovering from a common bile duct exploration and has a T-tube drain in place. As the nurse, which action is most appropriate to ensure proper function and patient safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D","F"]

Explanation

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A patient with a history of ulcerative colitis presents to the clinic with complaints of fatigue, dizziness, and pallor. Upon further assessment, you suspect chronic blood loss. Which potential complication is most likely contributing to these symptoms?

A nurse is reviewing medications for a client who has just been diagnosed with a small bowel obstruction. The nurse should withhold senna prescribed orally based on understanding of which of the following?

A patient is recovering from a common bile duct exploration and has a T-tube drain in place. As the nurse, which action is most appropriate to ensure proper function and patient safety?

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A patient with Crohn's disease is being discharged from the hospital. The nurse is providing dietary teaching to the patient. Which of the following statements by the patient indicates a correct understanding of the dietary recommendations?

A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?