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. Share personal items like razors and toothbrushes. Sharing personal items that may come in contact with blood or body fluids, like razors and toothbrushes, increases the risk of spreading hepatitis, so clients should avoid sharing these items.
B. Drink alcohol in moderation to avoid liver strain. Clients with hepatitis should avoid alcohol entirely, as alcohol can worsen liver inflammation and damage, which would strain the liver further.
C. Wash your hands thoroughly after using the bathroom. Hand hygiene is crucial, especially for hepatitis A, which can spread through fecal-oral transmission. Washing hands can prevent the spread of the virus to others.
D. Avoid all physical activities to conserve energy. Although clients may need to rest, they do not need to avoid all physical activity. Light, tolerated activity can help maintain strength and prevent complications from immobility.
Correct Answer is ["A","C","D","E"]
Explanation
A. Ensure that the client's urine output is at least 1 ml/kg/hr. Adequate urine output is essential before administering IV potassium to ensure the kidneys are functioning properly and can handle the increased potassium load, preventing hyperkalemia.
B. Ensure potassium infusion is prepared with 5% dextrose solution. While IV potassium can be mixed with normal saline or dextrose solutions, the specific diluent will depend on the clinical scenario. This isn't necessarily a standard requirement, so it may not be appropriate for all situations.
C. Educate the client regarding high-potassium foods. Education on high-potassium foods helps the client maintain potassium levels after treatment, reducing the need for future supplementation.
D. Repeat blood serum potassium levels. Rechecking potassium levels ensures the patient reaches a safe and therapeutic range and helps monitor for signs of overcorrection or continued hypokalemia.
E. Cardiac monitoring during infusion. Cardiac monitoring is critical, as hypokalemia and potassium replacement can affect heart rhythm and lead to arrhythmias.