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 C

Explanation

A. Elevate the head of the bed to 90 degrees: While elevating the head of the bed may help ease breathing, it does not address the potential issue of NG tube misplacement.

B. Administer a bronchodilator as prescribed: This would only be appropriate if the patient’s respiratory distress were related to bronchospasm or asthma, not NG tube displacement.

C. Check the placement of the NG tube to ensure it has not dislodged into the lungs. When a patient with an NG tube experiences respiratory distress, the tube may have dislodged and entered the respiratory tract, which could obstruct breathing. Verifying the placement of the NG tube is critical to preventing aspiration or further complications.

D. Increase the flow rate of the patient’s oxygen therapy: This may provide temporary relief but does not resolve the underlying cause of the distress if the NG tube has entered the respiratory tract.

A. I should eat large meals to reduce the frequency of acid reflux. B. I should drink peppermint tea after meals to help with digestion. C. I should lie down immediately after eating to prevent heartburn. D. I should avoid eating meals at least 2-3 hours before bedtime.

Correct Answer is D

Explanation

A. I should eat large meals to reduce the frequency of acid reflux: Large meals can worsen GERD by increasing stomach pressure and acid production, leading to reflux. Small, frequent meals are recommended instead.

B. I should drink peppermint tea after meals to help with digestion: While peppermint may help with general digestion, it can relax the lower esophageal sphincter (LES), making GERD worse by allowing acid to reflux into the esophagus.

C. I should lie down immediately after eating to prevent heartburn: Lying down after meals increases the likelihood of acid reflux due to gravity, especially if the stomach is full, and should be avoided.

D. I should avoid eating meals at least 2-3 hours before bedtime. Avoiding meals 2-3 hours before bedtime helps reduce acid reflux by preventing the stomach from being full and producing excess acid when lying down.

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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 C

Explanation

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Explanation

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