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. 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.

A. Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues. B. Use a floss pick instead of the floss string to floss in between the teeth. C. Apply an ice pack over a bleeding wound. D. Only use a soft-bristle toothbrush.

Correct Answer is D

Explanation

A. Wear sleeveless or short-sleeved shirts and shorts to better visualize any skin issues: While wearing loose or visible clothing may allow skin issues to be seen, it does not directly prevent bleeding complications, and there are more effective measures to focus on.

B. Use a floss pick instead of the floss string to floss in between the teeth: Flossing in any form, especially using a floss pick, can still increase the risk of gum bleeding in thrombocytopenic clients. It is safer to avoid flossing altogether or consult a dentist.

C. Apply an ice pack over a bleeding wound: While applying an ice pack may reduce bleeding once it occurs, it does not prevent bleeding. The focus should be on avoiding activities that increase the risk of bleeding.

D. Only use a soft-bristle toothbrush: Using a soft-bristle toothbrush helps reduce the risk of bleeding from the gums, which is a common issue for clients with thrombocytopenia due to the reduced platelet count.

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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 D

Explanation

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