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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.

Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.

Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.

Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.

A. Instruct the client to increase fluid intake. B. Notify the health care provider. C. Advise the client to take iron rich foods. D. Document the findings.

Correct Answer is B

Explanation

Choice A Reason: Instructing the client to increase fluid intake is not the most appropriate nursing action, as it does not address the cause or severity of the bleeding.

Choice B Reason: Notifying the health care provider is the most appropriate nursing action, as it indicates that the client may have a bleeding ulcer that requires immediate evaluation and treatment.

Choice C Reason: Advising the client to take iron rich foods is not the most appropriate nursing action, as it does not prevent or correct anemia or bleeding.

Choice D Reason: Documenting the findings is not the most appropriate nursing action, as it does not initiate any intervention or outcome.

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