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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Conjunctivitis. Conjunctivitis generally presents with redness and discharge but does not cause elevated intraocular pressure, severe pain, or visual disturbances like halos.

B. Acute angle-closure glaucoma. Acute angle-closure glaucoma is characterized by sudden severe eye pain, blurred vision, halos around lights, nausea, and vomiting, along with elevated intraocular pressure and a cloudy cornea.

C. Retinal detachment. Retinal detachment may cause sudden vision loss or flashing lights but typically lacks pain, nausea, or vomiting, and does not affect intraocular pressure.

D. Migraine with aura. A migraine with aura may cause visual disturbances but does not present with eye pain, red eye, or elevated intraocular pressure.

A. Administering pain medication B. Applying a cool, wet cloth to burned areas. C. Administering high flow oxygen via a non-rebreather mask D. Initiating intravenous fluid resuscitation

Correct Answer is C

Explanation

A. Administering pain medication: Pain management is essential, but in this case, the primary concern is potential airway compromise due to inhalation injury, which should be addressed first.

B. Applying a cool, wet cloth to burned areas: Cooling burned areas can help with pain and reduce burn severity but is not the priority in a case of suspected inhalation injury with airway compromise.

C. Administering high-flow oxygen via a non-rebreather mask: This client is at high risk for respiratory compromise due to inhalation injury; administering high-flow oxygen is the priority to ensure adequate oxygenation.

D. Initiating intravenous fluid resuscitation: Fluid resuscitation is essential for burn patients but is not the immediate priority over addressing potential airway and oxygenation issues.

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The nurse is caring for a patient with a T-tube following gallbladder surgery. Which of the following is the most important nursing action?

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