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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Correct Answer is A

Explanation

A. A low-fat diet: A low-fat diet is recommended for clients with chronic cholecystitis to reduce the workload on the gallbladder and prevent biliary colic, which can be triggered by the digestion of fats.

B. A low-sodium diet: While a low-sodium diet may be recommended for other conditions, it is not specifically indicated for biliary colic or cholecystitis.

C. A high-fiber diet: Although fiber is beneficial for overall health, it does not directly prevent biliary colic related to cholecystitis.

D. A high-protein diet:A high-protein diet is not recommended for biliary colic. Fat content is the primary concern, not protein.

A. Spider angioma B. Increased body hair C. Weak pulse D. Dark colored stools

Correct Answer is A

Explanation

A. Spider angioma: Spider angiomas are a common manifestation of advanced cirrhosis due to increased estrogen levels resulting from impaired liver function.

B. Increased body hair: Clients with cirrhosis often have decreased body hair due to hormonal imbalances and liver dysfunction, not increased body hair.

C. Weak pulse: While a weak pulse could indicate circulatory issues, it is not a common manifestation specific to cirrhosis. The nurse would expect signs like jaundice, ascites, or edema.

D. Dark-colored stools: Dark-colored stools are more commonly seen in cases of gastrointestinal bleeding or iron supplements. In cirrhosis, the stools are often pale or clay-colored due to bile flow obstruction.

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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

A nurse is reinforcing dietary instructions with a client who has episodes of biliary colic from chronic cholecystitis. Which of the following diets should the nurse reinforce in the teaching plan?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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