T-tubes should not be irrigated, aspirated, or clamped without
specific directions from the health care provider. All of the other actions are
appropriate in the care of this client. Focus: Supervision. - ANS-The nursing is supervising a
nursing student who is caring for a client who had a cholecystectomy. There is a T-tube in place.
The nurse would intervene if the student performs which action?
1. Maintains the client in a semi-Fowler position
2. Checks the amount, color, and consistency of the drainage
3. Gently aspirates the drainage from the tube
4. Inspects the skin around the tube for redness or irritation
ANS: C.
LPN/LVN education and scope of practice includes administration of insulin. Communication
about patient
status with other departments, planning, and patient teaching are skills that require RN
education and scope of practice. - ANS-When a patient with type 2 diabetes is admitted for a
cholecystectomy, which nursing action can the nurse
delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery.
b. Discuss the reason for the use of insulin therapy during the immediate postoperative period.
c. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
d. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the
postoperative
period
ANS: D
Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory
complications because the surgical incision is high in the abdomen and impairs coughing and
deep breathing. The other nursing actions are also important to implement but are not as high a
priority as ensuring adequate ventilation. - ANS-A 51-year-old woman had an incisional
cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to
a. choose low-fat foods from the menu.
b. perform leg exercises hourly while awake.
c. ambulate the evening of the operative day.
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