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 A
Explanation
A. Drink plenty of fluids to stay hydrated. Staying hydrated is essential in managing viral pharyngitis to prevent dehydration, soothe the throat, and promote recovery.
B. Take antibiotics as prescribed until the course is complete. Antibiotics are not indicated for viral infections; they are only used for bacterial infections.
C. Avoid all forms of physical activity until fully recovered. While rest is recommended, light activities may be acceptable depending on the patient’s energy levels and symptoms. Total avoidance of all physical activity is unnecessary.
D. Use throat lozenges as needed but avoid resting to prevent throat swelling. Resting is beneficial to recovery. Throat lozenges may soothe irritation, but avoiding rest would be counterproductive.
Correct Answer is C
Explanation
A. Loss of pain, temperature, and light touch sensation on the same side as the injury. In Brown-Sequard syndrome, pain, temperature, and light touch are typically lost on the opposite (contralateral) side of the injury.
B. Loss of motor function and deep pressure sensation on the opposite side of the injury. Motor function and deep pressure sensation loss occur on the same side (ipsilateral) as the injury.
C. Loss of motor function and position sense on the same side as the injury. Brown-Sequard syndrome is a spinal cord hemisection injury leading to loss of motor function and proprioception on the same side as the injury.
D. Loss of motor function with preserved pain and temperature sensation in the lower extremities. Pain and temperature sensations are lost on the opposite side of the injury in Brown-Sequard syndrome, not preserved.