A client who is 4 days post-cholecystectomy has T-tube drainage totaling 600 mL in 24 hours. Which actions by the nurse are appropriate based on this data? Select all that apply.
A)Notify the healthcare provider.
B)Place the client in a supine position.
C)Assess drainage characteristics.
D)Clamp the tube q 2 hours for 30 minutes.
E)Encourage increased fluid intake.

Question

Quizplus · Accepted Answer

A)The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily thereafter. If there is excessive drainage, as in this scenario, the nurse should further assess the drainage to be able to describe it accurately and notify the healthcare provider immediately. Clamping the tube would be contraindicated. Placing the client in a supine position and encouraging fluid intake are of no help.
B)The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily thereafter. If there is excessive drainage, as in this scenario, the nurse should further assess the drainage to be able to describe it accurately and notify the healthcare provider immediately. Clamping the tube would be contraindicated. Placing the client in a supine position and encouraging fluid intake are of no help.
C)The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily thereafter. If there is excessive drainage, as in this scenario, the nurse should further assess the drainage to be able to describe it accurately and notify the healthcare provider immediately. Clamping the tube would be contraindicated. Placing the client in a supine position and encouraging fluid intake are of no help.
D)The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily thereafter. If there is excessive drainage, as in this scenario, the nurse should further assess the drainage to be able to describe it accurately and notify the healthcare provider immediately. Clamping the tube would be contraindicated. Placing the client in a supine position and encouraging fluid intake are of no help.
E)The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily thereafter. If there is excessive drainage, as in this scenario, the nurse should further assess the drainage to be able to describe it accurately and notify the healthcare provider immediately. Clamping the tube would be contraindicated. Placing the client in a supine position and encouraging fluid intake are of no help.

A Client Who Is 4 Days Post-Cholecystectomy Has T-Tube Drainage