The nurse is precepting a student nurse on the medical-surgical unit who is caring for a client with a T-tube. Which statement by the student nurse regarding the care of the tube indicates a need for further teaching?
“I should report a sudden increase in bile output.”
“The client should be in a semi-Fowler’s position to promote drainage.”
“The drainage system should be kept below the level of the gallbladder.”
“I will clamp the tube if the client becomes nauseated or begins to vomit.”
Number 4 is correct.
Rationale: The T-tube should be clamped before meals and the client observed for nausea, chills, abdominal distention, or discomfort. If nausea or vomiting occurs, the tube should be unclamped. A sudden increase in bile output should be reported to the health care provider. The semi-Fowler’s position promotes drainage into the tube, along with keeping the drainage system below the level of the gallbladder.