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 C
Explanation
A. Initiate intravenous fluid therapy. While fluid therapy is essential to support circulation and reduce the risk of shock, oxygenation takes priority in fat embolism management.
B. Prepare the client for emergency surgery. Surgery is not typically the first-line intervention for fat embolism; management focuses on supportive care, particularly respiratory support.
C. Administer high-flow oxygen via a non-rebreather mask. High-flow oxygen is the first priority to address hypoxia caused by fat embolism and should be administered immediately to maintain adequate oxygenation.
D. Apply sequential compression devices (SCDs). SCDs are used to prevent venous thromboembolism, but they do not help with the treatment of fat embolism.
Correct Answer is D
Explanation
A. Hypotension: Patients with SIADH typically have fluid retention, which can lead to hypertension, not hypotension.
B. Dry mucous membranes: In SIADH, fluid retention is common, so mucous membranes are usually moist, not dry.
C. Increased thirst: While thirst can occur in various conditions, it is not a primary symptom of SIADH.
D. Confusion or altered mental status: Confusion or altered mental status may occur in SIADH due to hyponatremia from excessive water retention.