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 D

Explanation

Choice A reason: Nebulizer and pulse oximeter monitor breathing but are less critical than preparing for respiratory failure, a Guillain-Barré complication. Intubation equipment is essential, making this incorrect, as it’s secondary to the nurse’s priority of addressing potential airway compromise in the client.

Choice B reason: Blood pressure cuff and flashlight are useful but don’t address the risk of respiratory paralysis in Guillain-Barré. Intubation tray is critical, making this incorrect, as it’s less urgent than the nurse’s need to prepare for life-threatening respiratory complications in the client.

Choice C reason: Nasal cannula and spirometer support breathing but are inadequate for acute respiratory failure in Guillain-Barré. Electrocardiographic and intubation equipment are vital, making this incorrect, as it doesn’t prioritize the nurse’s preparation for the client’s potential rapid respiratory deterioration.

Choice D reason: Electrocardiographic electrodes and intubation tray are essential for Guillain-Barré, as ascending paralysis risks respiratory failure and autonomic dysfunction. This aligns with neurological emergency protocols, making it the correct choice for the nurse to bring to manage life-threatening complications effectively.

A. Hypertension. B. Crackles (rales) in the lung fields. C. Cutaneous cyanosis. D. Pruritus. E. Cough. F. Wheezing. G. Hypotension. H. Restlessness.

Correct Answer is ["C","D","F","G","H"]

Explanation

Choice A reason: Hypertension is not typical in anaphylactic shock, which causes vasodilation and hypotension. Hypotension is a key finding, making this incorrect, as it contradicts the expected cardiovascular response in the nurse’s assessment of a client with anaphylactic shock.

Choice B reason: Crackles indicate fluid overload or pneumonia, not anaphylaxis, which causes bronchoconstriction and wheezing. Pruritus is typical, making this incorrect, as it doesn’t align with the respiratory findings the nurse would expect in anaphylactic shock assessment.

Choice C reason: Cutaneous cyanosis reflects poor oxygenation from airway compromise in anaphylactic shock. This aligns with integumentary and respiratory assessment, making it a correct finding the nurse would identify in a client experiencing anaphylactic shock in the ED.

Choice D reason: Pruritus, often with hives, is a hallmark of anaphylactic shock due to histamine release. This aligns with allergic response assessment, making it a correct finding the nurse would expect in a client with anaphylactic shock in the emergency department.

Choice E reason: Cough may occur but is less specific than wheezing, which indicates bronchoconstriction in anaphylaxis. Hypotension is more critical, making this incorrect, as it’s not a primary finding compared to the nurse’s expected signs of anaphylactic shock.

Choice F reason: Wheezing results from bronchoconstriction in anaphylactic shock, reflecting airway narrowing. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

Choice G reason: Hypotension is a cardinal sign of anaphylactic shock due to vasodilation and fluid shifts. This aligns with cardiovascular assessment, making it a correct finding the nurse would identify in a client with anaphylactic shock in the emergency setting.

Choice H reason: Restlessness indicates hypoxia or anxiety in anaphylactic shock, a common neurological response. This aligns with clinical assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

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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

Correct Answer is D

Explanation

The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock? (Select all that apply)

Correct Answer is ["C","D","F","G","H"]

Explanation

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