The nurse notes that a client’s T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

Clamp the T-tube.

Irrigate the T-tube.

Notify the surgeon.

Document the findings.

Answer and Explanation

The Correct Answer is C

Choice A reason: Clamping the T-tube risks bile backup and infection, especially with 750 mL drainage. Notifying the surgeon addresses potential complications, making this incorrect, as it’s unsafe compared to the nurse’s priority of reporting excessive T-tube output.

Choice B reason: Irrigating the T-tube without medical orders risks dislodging it or causing infection. Notifying the surgeon is appropriate for 750 mL drainage, making this incorrect, as it’s risky compared to the nurse’s action to seek medical evaluation.

Choice C reason: Notifying the surgeon is most appropriate, as 750 mL of T-tube drainage may indicate a complication like bile leak or obstruction. This aligns with post-surgical care protocols, making it the correct intervention for the nurse to address excessive drainage.

Choice D reason: Documenting is necessary but doesn’t address the potential complication of 750 mL drainage. Notifying the surgeon is urgent, making this incorrect, as it delays the nurse’s priority of reporting a significant post-surgical T-tube output to the surgeon.

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Correct Answer is A

Explanation

Choice A reason: Starting IV fluids is the first action to correct hypotension (72/48) and tachycardia (152) in burn shock, restoring perfusion. This aligns with burn resuscitation protocols, making it the correct action to address the client’s critical hypovolemia and absent pedal pulses immediately.

Choice B reason: Albumin is used later in burn management, not first, as crystalloids like saline restore volume. IV fluids address hypovolemia, making this incorrect, as it’s premature compared to the nurse’s priority of initiating fluid resuscitation in the burn-injured client.

Choice C reason: Checking pulses with Doppler assesses perfusion but delays fluid resuscitation needed for hypotension and shock. IV fluids are urgent, making this incorrect, as it’s secondary to the nurse’s first action of correcting hypovolemia in the burn client’s emergency care.

Choice D reason: Calculating the rule of nines guides fluid volume but is secondary to starting IV fluids for hypotension. Immediate resuscitation is critical, making this incorrect, as it delays the nurse’s priority of addressing the client’s shock state in the burn emergency.

A. Select foods high in fat. B. Increase intake of fluids, including juices. C. Eat a good supper, when anorexia is less severe. D. Eat less often, preferably only three large meals daily.

Correct Answer is B

Explanation

Choice A reason: High-fat foods may worsen nausea in hepatitis, reducing appetite further. Fluids and juices provide nutrition and hydration, making this incorrect, as it’s less suitable than the nurse’s recommendation to ensure adequate nutrition in a client with anorexia.

Choice B reason: Increasing fluid intake, including nutrient-rich juices, provides calories and hydration, combating anorexia in hepatitis. This aligns with nutritional support strategies, making it the correct instruction the nurse would give to ensure adequate nutrition for the client.

Choice C reason: Supper timing doesn’t address overall anorexia; small, frequent meals are better. Juices provide easier nutrition, making this incorrect, as it’s less effective than the nurse’s advice to increase fluids for a hepatitis client with poor appetite.

Choice D reason: Three large meals may overwhelm a client with hepatitis and anorexia, worsening intake. Fluids and juices are easier to tolerate, making this incorrect, as it’s not the nurse’s best instruction for ensuring adequate nutrition in this client.

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The nurse notes that a client’s T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

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Naxlex Comprehensive Predictor Exams

A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

Correct Answer is A

Explanation

A client diagnosed with viral hepatitis is complaining of “no appetite” and “losing my taste for food.” What instruction would the nurse give the client to provide adequate nutrition?

Correct Answer is B

Explanation

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