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 symptoms best describes Murphy’s sign?

Correct answer: C

Rationale: Murphy's sign is described as pain elicited on deep inspiration when the examiner's fingers are placed under the right costal margin.

3. A client with gastric cancer may exhibit which of the following symptoms?

Correct answer: C

Rationale: Clients with gastric cancer may experience a feeling of fullness due to the presence of the tumor.

4. When counseling a client in ways to prevent cholecystitis, which of the following guidelines is most important?

Correct answer: B

Rationale: Eating a low-fat, low-cholesterol diet is most important for preventing cholecystitis.

5. Which of the following symptoms is a client with colon cancer most likely to exhibit?

Correct answer: B

Rationale: A change in bowel habits is the most common symptom of colon cancer.

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