The nurse is caring for a patient with a T-tube following gallbladder surgery. Which of the following is the most important nursing action?
Keep the patient NPC (nothing by mouth) until the T-tube is removed.
Monitor the tube drainage and document the amount and color.
Ensure the tube is clamped for 8 hours each day.
Flush the T-tube with normal saline every 4 hours.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Otosclerosis. Otosclerosis is a common cause of conductive hearing loss, typically due to abnormal bone growth around the stapes in the middle ear.
B. Acoustic neuroma. Acoustic neuroma is associated with sensorineural hearing loss, not conductive hearing loss.
C. Meniere's disease. Meniere's disease usually causes sensorineural hearing loss, often accompanied by vertigo and tinnitus.
D. Presbycusis. Presbycusis is age-related sensorineural hearing loss and does not result in conductive hearing loss.
Correct Answer is A
Explanation
A. Increased pulse, respirations and blood pressure with dysphagia and respiratory distress. A myasthenic crisis is characterized by severe muscle weakness that can lead to respiratory failure, dysphagia, and increased vital signs due to the stress of respiratory distress.
B. Hypotension, diarrhea, and increased salivation. These symptoms are more indicative of a cholinergic crisis, which is due to excess acetylcholine.
C. Bradycardia and hypothermia. Bradycardia and hypothermia are not characteristic signs of a myasthenic crisis.
D. Tachypnea and hyperactive deep tendon reflexes. While tachypnea can occur in respiratory distress, hyperactive reflexes are not typical in myasthenic crisis, as it involves neuromuscular weakness.
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