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 C

Explanation

Choice A reason: Pulse pressure is calculated as systolic (90) minus diastolic (72), equaling 18 mm Hg, not 40. This is incorrect, as it overestimates the pulse pressure, unlike the nurse’s accurate calculation based on the patient’s blood pressure readings.

Choice B reason: A pulse pressure of 25 mm Hg doesn’t match the calculation of 90 minus 72, which is 18 mm Hg. This is incorrect, as it’s inaccurate compared to the nurse’s correct determination of the patient’s pulse pressure from the given values.

Choice C reason: Pulse pressure is systolic (90 mm Hg) minus diastolic (72 mm Hg), equaling 18 mm Hg. This aligns with cardiovascular assessment, making it the correct value the nurse would calculate for the patient’s blood pressure of 90/72 mm Hg.

Choice D reason: A pulse pressure of 12 mm Hg is incorrect, as 90 minus 72 equals 18 mm Hg. This underestimates the value, making it incorrect compared to the nurse’s accurate calculation of the patient’s pulse pressure based on the blood pressure.

A. Disagreements among health care team members. B. Failure to discuss end-of-life issues with patient. C. Aggressive pain management. D. Belief that treatment is harmful. E. Following the patient’s advance directive despite family objections. F. Providing hope to the patient’s family.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Disagreements among team members signal conflicting values, an early ethical dilemma indicator. This aligns with healthcare ethics, making it a correct situation, as it highlights potential ethical tensions that the nurse should recognize as requiring resolution in patient care.

Choice B reason: Failure to discuss end-of-life issues with the patient violates autonomy, creating an ethical dilemma. This aligns with ethical principles of patient involvement, making it a correct early sign the nurse should identify in healthcare decision-making processes.

Choice C reason: Aggressive pain management is a clinical decision, not inherently an ethical dilemma unless harm is suspected. Disagreements or belief in harm are clearer signs, making this incorrect, as it lacks the ethical conflict context in the nurse’s evaluation.

Choice D reason: Believing treatment is harmful raises ethical concerns about beneficence and nonmaleficence, indicating a dilemma. This aligns with ethical care standards, making it a correct situation the nurse should recognize as an early sign of an ethical issue in treatment decisions.

Choice E reason: Following an advance directive despite family objections creates an ethical conflict between patient autonomy and family wishes. This aligns with end-of-life ethics, making it a correct early sign of a dilemma the nurse should identify in patient care.

Choice F reason: Providing hope to the family is supportive and not inherently an ethical dilemma unless it involves deception. Failure to discuss end-of-life issues is a clearer sign, making this incorrect, as it lacks the ethical conflict context in the nurse’s assessment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient’s blood pressure is 90/72 mm Hg. What is the patient’s pulse pressure?

Correct Answer is C

Explanation

Which situations are early signs of an ethical dilemma? (Select all that apply)

Correct Answer is ["A","B","D","E"]

Explanation

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