the nurse develops a plan of care for a client with a t tube which one of the following nursing interventions should be included
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?

Correct answer: A

Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.

2. A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?

Correct answer: B

Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Documenting the amount and characteristics of the drainage is appropriate. The nurse does not need to notify the physician because this is an expected finding. Applying ice or pressure to the site is not necessary.

3. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?

Correct answer: D

Rationale: Understanding that family needs to be aware of symptoms that may indicate a recurrence of hepatitis B shows proper understanding by the patient.

4. Glenda has cholelithiasis (gallstones). You expect her to complain of:

Correct answer: A

Rationale: Patients with cholelithiasis often complain of pain in the right upper quadrant, radiating to the shoulder.

5. When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:

Correct answer: D

Rationale: Convalescence after hepatitis A may take weeks or even months. Boredom and depression are common problems that the client should anticipate. Abdominal pain is not usually a symptom of hepatitis A. Maintaining a regular bowel elimination pattern is not usually a problem with hepatitis. Problems preventing respiratory complications are unlikely. To support healing, activity is strictly limited but bed rest is not prescribed.

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