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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Pain of 8/10 is significant, but the patient is receiving opioids, and pain is less immediately life-threatening than hypotension and lethargy. This is incorrect, as it’s lower priority than the nurse’s need to address a patient with unstable vital signs.

Choice B reason: Minor bloating post-colonoscopy is expected and stable, not requiring immediate intervention. Hypotension in heart failure is critical, making this incorrect, as it’s less urgent than the nurse’s priority to manage a patient with potential decompensation.

Choice C reason: Confusion in new Type 1 diabetes may indicate hypoglycemia, but hypotension and lethargy in heart failure suggest acute decompensation, a higher priority. This is incorrect, as it’s less critical than the nurse’s focus on the heart failure patient’s instability.

Choice D reason: Hypotension (90/60 mmHg) and lethargy in a heart failure patient indicate possible cardiogenic shock, requiring immediate intervention. This aligns with prioritization in acute care, making it the correct patient for the charge nurse to prioritize for urgent assessment and action.

A. Administer oxygen to the client. B. Continue dialysis at a slower rate after checking the lines for air. C. Notify the primary health care provider (PHCP) and Rapid Response Team. D. Stop dialysis, and turn the client on the left side with head lower than feet. E. Bolus the client with 500 mL of normal saline to break up the air embolus.

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Administering oxygen improves oxygenation in air embolism, addressing hypoxia from chest pain and shortness of breath. This aligns with emergency dialysis protocols, making it a correct priority action the nurse would take to stabilize the client’s condition.

Choice B reason: Continuing dialysis, even slowly, risks worsening air embolism by introducing more air. Stopping dialysis is critical, making this incorrect, as it’s unsafe compared to the nurse’s priority of halting the procedure to prevent further embolism complications.

Choice C reason: Notifying the provider and Rapid Response Team ensures rapid intervention for air embolism, a life-threatening dialysis complication. This aligns with emergency protocols, making it a correct priority action the nurse would take to manage the client’s acute condition.

Choice D reason: Stopping dialysis and positioning the client on the left side with head down traps air in the right atrium, preventing pulmonary embolism. This is a standard intervention, making it a correct priority action for the nurse to address air embolism.

Choice E reason: Bolusing 500 mL saline doesn’t break up air emboli and risks fluid overload in kidney disease. Oxygen administration is appropriate, making this incorrect, as it’s ineffective compared to the nurse’s priority actions for managing air embolism.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

Correct Answer is D

Explanation

A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?

A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?

During transport to the operating room for mitral valve replacement, a patient with a signed consent form says that she does not want to go through with the surgery and asks to be returned to her room. What is the best response from the nurse?

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

The nurse monitoring a client receiving peritoneal dialysis notes that the client’s outflow is less than the inflow. Which actions would the nurse take? (Select all that apply)

The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption?

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items would the nurse include on this list? (Select all that apply)

The nurse is caring for a client with ulcerative colitis. Which findings does the nurse determine is consistent with this diagnosis? (Select all that apply)