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. Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

Correct answer: D

Rationale: Intestinal tubes are not irrigated. Injecting air into the tube, applying water-soluble lubricant, and coiling extra tubing are appropriate nursing measures.

3. Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for this patient?

Correct answer: C

Rationale: Serum amylase and lipase levels are typically elevated in patients with acute pancreatitis.

4. The nurse is reviewing the physician’s orders written for a client admitted with acute pancreatitis. Which physician order would the nurse question if noted on the client’s chart?

Correct answer: D

Rationale: Morphine for pain should be questioned as it can cause spasms of the sphincter of Oddi, worsening pancreatitis.

5. Risk factors for the development of hiatal hernias are those that lead to increased abdominal pressure. Which of the following complications DOES NOT cause increased abdominal pressure?

Correct answer: B

Rationale: Obesity, constipation, and intestinal obstruction can all lead to increased abdominal pressure, which in turn can cause a hiatal hernia.

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