A nurse is caring for a client post-cholecystectomy with a T-tube in place. Which nursing action is appropriate?
Keep the drainage bag above the level of the abdomen
Clamp the T-tube 2 hours before and after meals
Encourage a high-fat diet to stimulate bile flow
Assess and record the color and amount of drainage
The Correct Answer is D
Choice A reason: Keeping the drainage bag above the abdomen is incorrect, as it would impede bile drainage by gravity. The T-tube bag should be below the abdomen to facilitate bile flow and prevent backup, which could cause infection or bile peritonitis in post-cholecystectomy care.
Choice B reason: Clamping the T-tube before and after meals is not standard practice. Clamping may be done temporarily to assess bile flow before T-tube removal, but routine clamping risks bile accumulation, potentially causing leaks or infection, making this an inappropriate nursing action.
Choice C reason: Encouraging a high-fat diet is contraindicated post-cholecystectomy, as it may overwhelm the bile system, causing discomfort or complications, especially with a T-tube. A low-fat diet is recommended to minimize bile demand, making this action incorrect for safe patient recovery.
Choice D reason: Assessing and recording T-tube drainage color and amount is critical to monitor bile output, detect blockages, or identify complications like infection or bile leak. Normal bile is green-yellow; changes may indicate issues, making this the appropriate nursing action for post-cholecystectomy care with a T-tube.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Increased thirst (polydipsia) is a symptom of hyperglycemia, not hypoglycemia, in type 1 diabetes. It results from osmotic diuresis due to elevated glucose, not low glucose levels, making it irrelevant for immediate intervention in a hypoglycemic crisis requiring rapid glucose administration.
Choice B reason: Tremors and sweating are classic signs of hypoglycemia in type 1 diabetes, caused by sympathetic nervous system activation and catecholamine release in response to low blood glucose. These indicate an urgent need for glucose to prevent seizures or unconsciousness, making this the priority symptom.
Choice C reason: Increased appetite (polyphagia) is associated with hyperglycemia, not hypoglycemia, as cells are starved of glucose due to insulin deficiency. It does not require immediate intervention in a hypoglycemic context, as it reflects a different metabolic state, making this symptom less urgent.
Choice D reason: Frequent urination (polyuria) is a hyperglycemia symptom, driven by osmotic diuresis from high glucose levels, not hypoglycemia. It does not indicate an acute crisis requiring immediate action, unlike tremors and sweating, which signal a potentially life-threatening low glucose state.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Diabetic neuropathy is a common diabetes complication, resulting from chronic hyperglycemia damaging peripheral nerves. This leads to sensory loss, pain, or autonomic dysfunction, impairing sensation in extremities, increasing infection risk, and affecting quality of life, making it a significant and well-recognized complication.
Choice B reason: Nausea, vomiting, and diarrhea are not primary diabetes complications but may occur secondary to conditions like gastroparesis or infections. They are symptoms, not chronic complications, and are less specific to diabetes compared to neuropathy or vascular issues, making this incorrect.
Choice C reason: Microvascular complications, including retinopathy, nephropathy, and neuropathy, result from hyperglycemia damaging small blood vessels. This leads to retinal ischemia, kidney dysfunction, or nerve damage, contributing to blindness, renal failure, or sensory loss, making this a major category of diabetes complications requiring long-term management.
Choice D reason: Macrovascular complications, such as coronary artery disease, stroke, and peripheral artery disease, arise from hyperglycemia-induced atherosclerosis. Diabetes accelerates endothelial damage and plaque formation, increasing cardiovascular risk, making this a critical complication category, as it significantly contributes to morbidity and mortality in diabetic patients.
Choice E reason: Diabetic retinopathy, caused by hyperglycemia damaging retinal blood vessels, leads to microaneurysms, hemorrhages, and neovascularization, potentially causing blindness. It is a leading cause of vision loss in diabetes, making this a specific and severe microvascular complication requiring regular screening and intervention.
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