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. Ciprofloxacin, Metronidazole, and Ranitidine: Ciprofloxacin and ranitidine are not recommended for H. pylori treatment. Ciprofloxacin is not typically used, and ranitidine is an H2 blocker, not a proton pump inhibitor.
B. Amoxicillin, Clarithromycin, and Omeprazole: This combination is a standard triple therapy for H. pylori infection. Amoxicillin and clarithromycin are antibiotics, and omeprazole (a proton pump inhibitor) reduces stomach acid to help eradicate the bacteria.
C. Metronidazole, Tetracycline, and Bismuth subsalicylate: This combination is part of quadruple therapy rather than triple therapy. Quadruple therapy is usually reserved for cases resistant to initial treatment.
D. Erythromycin, Amoxicillin, and Famotidine: Erythromycin is not part of standard triple therapy, and famotidine is an H2 blocker, not a proton pump inhibitor.
Correct Answer is C
Explanation
A. Influenza: Influenza typically presents with a high fever, muscle aches, and fatigue, which are not present in this case.
B. Strep Throat: Strep throat usually presents with a sore throat, high fever, and swollen lymph nodes, not nasal congestion or watery eyes.
C. Rhinitis: Rhinitis, particularly allergic rhinitis, causes symptoms such as sneezing, nasal congestion, watery eyes, and malaise without fever, making it the most likely diagnosis.
D. Bacterial Pharyngitis: Bacterial pharyngitis often presents with a sore throat, fever, and swollen lymph nodes, but typically does not include nasal congestion or watery eyes.