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. The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?

Correct answer: C

Rationale: Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative period, but peripheral tissue perfusion is the most immediate concern.

3. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include?

Correct answer: B

Rationale: Instruct the patient to lie on their right side after the biopsy to apply pressure and prevent bleeding.

4. You promote hemodynamic stability in a patient with upper GI bleeding by:

Correct answer: D

Rationale: Promoting hemodynamic stability in a patient with upper GI bleeding involves giving blood, electrolyte, and fluid replacement.

5. Surgical management of ulcerative colitis may be performed to treat which of the following complications?

Correct answer: D

Rationale: Surgical management of ulcerative colitis may be necessary to treat complications such as bowel perforation.

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