The nurse should include which teaching points when planning discharge for a patient who has a T-tube following a cholecystectomy? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Keep the skin around the site clean and free from bile drainage.
2. Report drainage of more than 500 mL per day to the health care provider.
3. Primarily maintain a side-lying position to facilitate drainage.
4. Report skin redness or irritation in the drain site area.
5. Pin the drainage tube to clothing to maintain slight traction on the site.
1,2,4
Rationale 1: Bile is irritating to the skin. The area around the tube site should be protected from bile drainage and cleaned frequently.
Rationale 2: Drainage of more than 500 mL in a discharged patient should be reported to the primary health care provider.
Rationale 3: A Fowler's position facilitates drainage best.
Rationale 4: Redness or irritation at the drain site should be reported to the primary health care provider.
Rationale 5: The drainage device and tubing should be positioned to avoid pulling on the tubing.
You might also like to view...
The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
a. "I plan to wear my oxygen when I exercise and feel short of breath." b. "I will use my portable oxygen when grilling burgers in the backyard." c. "I plan to use cotton balls to cushion the oxygen tubing on my ears." d. "I will only smoke while I am wearing my oxygen via nasal cannula."
You are assigned to the position of triage nurse in the emergency department. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2°C
The patient is alcohol impaired at the time of admission and undernourished. The priority for care in this patient is what? A) Hypothermia B) Frostbite C) Substance abuse D) Alteration in nutrition
During the assessment of a patient's voice sounds, the nurse hears increased and clear sounds over the patient's right lower lobe. This finding is consistent with which health problem?
1. emphysema 2. lobar pneumonia 3. asthma 4. pleural effusion
A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess?
a. severe sore throat, drooling, and inspiratory strider b. low grade fever, stridor, and a barking cough c. pulmonary congestion, a productive cough, and a fever d. sore throat, a fever, and general malaise