Nursing Elites

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?

• A. Inspect skin around the T tube daily for irritation.
• B. Irrigate the T tube every 4 hours to maintain patency.
• C. Maintain the client in a supine position while the T tube is in place.
• D. Keep the T tube clamped except during mealtimes.

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. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.

3. The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which of the following signs and symptoms, if identified by the client, indicates an understanding of this potential complication following gastrointestinal surgery?

• A. Hiccups and diarrhea
• B. Fatigue and abdominal pain
• C. Constipation and fever
• D. Diaphoresis and diarrhea

Correct answer: D

Rationale: The correct answer is D: Diaphoresis and diarrhea. Dumping syndrome occurs after gastric surgery when food moves quickly from the stomach to the intestine, causing fluid shifts and leading to symptoms like weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain, distension, hyperactive bowel sounds, and diarrhea. Choices A, B, and C do not reflect the typical signs and symptoms of dumping syndrome.

4. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to:

• A. Empty her bladder.
• B. Lie supine in bed.
• C. Remain NPO for 4 hours.
• D. Clean her bowels with an enema.

Correct answer: A

Rationale: Before paracentesis, instruct the patient to empty her bladder to avoid bladder injury during the procedure.

5. You’re caring for a patient with a sigmoid colostomy. The stool from this colostomy is:

• A. Formed
• B. Semisolid
• C. Semiliquid
• D. Watery

Correct answer: A

Rationale: The stool from a sigmoid colostomy is typically formed.

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