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

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.

A. Instruct the patient to change positions slowly prevent dizziness and falls. B. Advise the patient to avoid all physical activity to prevent exacerbation of symptoms. C. Encourage the patient to drink plenty of fluids to prevent dehydration. D. Recommend wearing tight clothing to support the abdominal area.

Correct Answer is A

Explanation

A. Instruct the patient to change positions slowly to prevent dizziness and falls. Ascites can cause a shift in fluid balance, leading to orthostatic hypotension. Changing positions slowly reduces the risk of dizziness and falls, which are common in patients with fluid shifts.

B. Advise the patient to avoid all physical activity to prevent exacerbation of symptoms: Complete avoidance of physical activity is not recommended. Mild activity may help with overall health and mobility unless contraindicated. Bedrest is typically only recommended for acute or severe cases.

C. Encourage the patient to drink plenty of fluids to prevent dehydration: Patients with ascites are often on fluid restrictions to manage excess fluid accumulation. Encouraging excess fluid intake can worsen the condition.

D. Recommend wearing tight clothing to support the abdominal area: Tight clothing could cause discomfort and increase abdominal pressure, which could exacerbate symptoms or complications related to ascites.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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