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.
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. High fluid intake: High fluid intake can help maintain blood flow and reduce the risk of venous stasis.
B. Immobility during and after surgery: Immobility contributes to venous stasis and is a primary risk factor for DVT, especially after prolonged surgery.
C. Low body temperature: Low body temperature does not directly cause venous stasis or increase the risk of DVT.
D. Increased physical activity: Increased physical activity promotes circulation and reduces the risk of DVT by preventing blood from pooling in the veins.
Correct Answer is D
Explanation
A. Pulmonary Function Test (PFT). PFTs assess lung function but do not provide diagnostic information for infections like pneumonia.
B. Electrocardiogram (ECG). An ECG assesses heart function and would not help in diagnosing a respiratory infection like pneumonia.
C. Complete Blood Count (CBC). A CBC may indicate infection through elevated white blood cells, but it does not confirm pneumonia or identify its location in the lungs.
D. Chest X-ray. A chest X-ray is the most useful diagnostic tool to confirm pneumonia. It can reveal infiltrates or consolidation in the lungs, which are characteristic of pneumonia.