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. While caring for a client with peptic ulcer disease, the client reports that he has been nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take?

Correct answer: B

Rationale: Monitoring the client's vital signs and notifying the physician of the client's symptoms are crucial actions based on the reported symptoms.

3. Your patient Maria takes NSAIDS for her degenerative joint disease, has developed peptic ulcer disease. Which drug is useful in preventing NSAID-induced peptic ulcer disease?

Correct answer: C

Rationale: Misoprostol (Cytotec) is useful in preventing NSAID-induced peptic ulcer disease.

4. The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client’s record, would the nurse question?

Correct answer: B

Rationale: Indomethacin (Indocin) is an NSAID that can aggravate acute gastritis and should be questioned.

5. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

Correct answer: B

Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.

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