Ati lpn med surg exam
Ati lpn med surg exam ( 49 Questions)
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 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.
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.
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.
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.
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.