The healthcare provider ordered an IV solution for a dehydrated client with a skull fracture. The nurse knows which IV fluid would be contraindicated?

Choice A reason: Securing the drain to the client's bed sheet is not the best action for the nurse to take. This could cause the drain to be pulled or dislodged if the client moves or changes position. The nurse should secure the drain to the client's gown or abdominal binder, using a safety pin or a clip.

Choice B reason: Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze, is not the correct action for the nurse to take. The nurse should not remove the drain without a physician's order, as this could cause complications such as infection, bleeding, or bile leakage. The nurse should monitor the amount and color of the drainage, and report any changes to the physician.

Choice C reason: Expelling the air from the JP bulb after emptying to re-establish suction is the correct action for the nurse to take. The JP drain works by creating a negative pressure that draws fluid from the surgical site. The nurse should empty the bulb when it is half full, and squeeze it until it collapses before closing the plug. This ensures that the suction is maintained and prevents the fluid from flowing back into the drain.

Choice D reason: Measuring the drainage every hour for the first 8 hr postoperative is not the correct action for the nurse to take. This is too frequent and unnecessary, as the drainage is expected to decrease over time. The nurse should measure the drainage every 8 to 12 hr, or as ordered by the physician, and record the volume and color. The nurse should also report any signs of infection, such as fever, pain, or foul odor.

Choice A reason: Including foods high in starch and proteins is not a specific dietary instruction for a client who has biliary colic from chronic cholecystitis. Starch and protein intake may vary depending on the client's overall nutritional needs and preferences.

Choice B reason: Including foods high in fiber is a general dietary recommendation for most people, but it is not directly related to biliary colic or cholecystitis. Fiber helps with bowel regularity and may lower the risk of some chronic diseases, but it does not affect the production or flow of bile.

Choice C reason: Avoiding foods high in sodium is a dietary instruction for clients who have hypertension, heart failure, or kidney disease, but it is not relevant for biliary colic or cholecystitis. Sodium intake does not influence the formation or dissolution of gallstones, which are the main cause of biliary colic.

Choice D reason: Avoiding foods high in fat is a dietary instruction for clients who have biliary colic from chronic cholecystitis. Fat intake stimulates the contraction of the gallbladder, which can cause pain and inflammation if there are gallstones blocking the bile ducts. Reducing fat intake can help prevent or reduce the frequency and severity of biliary colic episodes.