The nurse contributes to the plan of care for a patient who has a nursing diagnosis of Deficient Fluid Volume related to anorexia, nausea, vomiting, and excessive T-tube drainage related to cholecystitis
Which interventions should the nurse recommend be included in the plan of care? (Select all that apply.)
a. Monitor daily weight and intake and output.
b. Administer antiemetics as ordered.
c. Contact the physician if T-tube drainage is greater than 150 mL within 24 hours of surgery.
d. Clamp T-tube for 2 hours each shift.
e. Monitor skin turgor.
f. Encourage use of incentive spirometer every hour while awake.
ANS: A, B, E
Daily weights, intake and output, and skin turgor are good measures of fluid balance. Antiemetics will help reduce vomiting and contribute to fluid balance. About 250 to 500 mL of yellowish-green bile is common within the first 24 hours after surgery. Clamping the T-tube is inappropriate and may put pressure on the surgical site.
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