Nokea
When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:
- A. 50-100 mL
- B. 200-300 mL
- C. 300-500 mL
- D. 1000-1200 mL
Correct Answer: C
Rationale: During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about 200 mL in 24 hours during the next 3-4 days. This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. During the first 24 hours after surgery, this range is the expected amount of drainage. The expected amount of drainage during the first 24 hours is 300-500 mL. An output of >500 mL should be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.
You may also like to solve these questions
A client with a history of chronic kidney disease is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring for anemia
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering diuretics
Correct Answer: A
Rationale: Fatigue in chronic kidney disease often results from anemia due to low erythropoietin, so monitoring for anemia is the priority.
Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:
- A. Tetralogy of Fallot
- B. Ventricular septal defect
- C. Patent ductus arteriosus
- D. Transposition of the great arteries
Correct Answer: A
Rationale: Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood to reach the systemic circulation. A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the Systemic circulation. In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.
The nurse is providing dietary teaching for a client with hypertension. Which food should be avoided by the client on a sodium-restricted diet?
- A. Dried beans
- B. Swiss cheese
- C. Peanut butter
- D. Colby cheese
Correct Answer: D
Rationale: Colby cheese is high in sodium, which should be avoided on a sodium-restricted diet to manage hypertension, unlike the other options, which are lower in sodium.
The nurse is caring for a client with a history of cirrhosis. The nurse should give priority to:
- A. Monitoring for bleeding
- B. Administering diuretics
- C. Monitoring blood glucose
- D. Assessing for infection
Correct Answer: A
Rationale: Cirrhosis impairs clotting factor production, increasing bleeding risk, so monitoring for bleeding is a priority.
Which actions should be utilized prior to performing a tub bath on the 80 year-old client?
- A. Fill the tub one-half full of water at should be 46°C.
- B. Put a rubber mat on the bottom of the tub.
- C. Maintain water flow pressure during the bath.
- D. Check water temperature using a bath thermometer.
- E. Wash and dry the client's back moving from shoulders to buttocks.
- F. Perform back massage upon completion of the bath.
Correct Answer: B, D
Rationale: For an 80-year-old client, safety and comfort are priorities during a tub bath. A rubber mat (B) prevents slipping, crucial for elderly clients with reduced mobility. Checking water temperature with a bath thermometer (D) ensures the water is safe (typically 38-40°C, as 46°C is too hot). Filling the tub half full at 46°C (A) risks burns, and maintaining water flow pressure (C) is unnecessary and unsafe. Washing the back (E) and performing a massage (F) occur during or after the bath, not prior.