A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?
a. Notify the patient's surgeon.
b. Place the patient on bed rest.
c. Document the color and amount of drainage.
d. Irrigate the T-tube with sterile normal saline.
ANS: C
A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.
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At 10 PM, an older male resident is attempting to climb over the bedrails. Which inter-vention should the nurse implement first?
a. Talk to the resident about his behavior. b. Call the physician and ask for sedation. c. Apply a vest restraint onto the resident. d. Get a companion to keep him in the bed.
Recognizing the prevalence and incidence of dehydration among older adults, a care aide at a long-term care facility is in the habit of encouraging residents to drink even though they may not feel thirsty at the time. Which of the following facts underlies the care aide's advice?
A),Older adults often experience a decrease in the sensation of thirst, even when serum sodium levels are high. B) The metabolic needs for both fluid and sodium in older adults differ from those of younger individuals. C) Regulation and maintenance of effective circulating volume by the kidneys is less effective in the elderly. D) The renin-angiotensin-aldosterone system (RAAS) is less able to facilitate sodium clearance in older adults.
Using medical abbreviations is an effective way to communicate with the client
Answer the above statement true (T) or false (F).
Once the OR team has assembled in the room, the circulating nurse calls for a time out. What action should the nurse take during the time out?
a. ensure that sufficient surgical supplies are available b. check that all surgical personnel are properly attired c. review the scheduled procedure, site, and client. d. confirm that informed consent has been obtained