A patient with active gastrointestinal bleeding is being monitored for complications. Which of the following signs indicates the patient is developing hypovolemic shock?

A. Keep the patient NPO (nothing by mouth) until the T-tube is removed. Patients are generally kept NPO initially but may resume clear liquids and progress to a regular diet based on tolerance; NPO status is not required until the T-tube is removed.

B. Monitor the tube drainage and document the amount and color. Monitoring and documenting drainage from the T-tube is crucial to assess biliary function and ensure that the bile is draining properly, indicating no obstruction.

C. Ensure the tube is clamped for 8 hours each day. Clamping may be done before tube removal to test the body’s tolerance to bile drainage, but it should be done only as per physician orders, not routinely for 8 hours each day.

D. Flush the T-tube with normal saline every 4 hours. Flushing a T-tube is generally not done routinely as it could disrupt the flow of bile and cause complications.

A. Administer high-calorie diet to prevent weight loss. While adequate nutrition is important, a high-calorie diet is not the primary priority in managing heart failure. Sodium and fluid management are usually more crucial to control fluid overload.

B. Reduce sodium intake to help manage fluid retention. Reducing sodium intake is a priority in heart failure management as it helps prevent fluid retention, which reduces workload on the heart and decreases symptoms of fluid overload.

C. Encourage complete bed rest to reduce cardiac workload. Complete bed rest is not recommended as it can lead to deconditioning and increased risk of blood clots. Activity should be balanced according to the patient’s tolerance.

D. Increase fluid intake to maintain hydration. In heart failure, increasing fluid intake could worsen fluid overload. Fluid restriction may be necessary to prevent excess fluid retention.