Nokea
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.
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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?
- A. Digoxin (Lanoxin)
- B. Indomethacin (Indocin)
- C. Furosemide (Lasix)
- D. Propranolol hydrochloride (Inderal)
Correct Answer: B
Rationale: Indomethacin (Indocin) is a Nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, duodenum, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Digoxin is an antidysrhythmic. Propranolol (Inderal) is a B- adrenergic blocker. Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders.
A 40-year-old male client has been hospitalized with peptic ulcer disease. He is being treated with a histamine receptor antagonist (cimetidine), antacids, and diet. The nurse doing discharge planning will teach him that the action of cimetidine is to:
- A. Reduce gastric acid output
- B. Protect the ulcer surface
- C. Inhibit the production of hydrochloric acid (HCl)
- D. Inhibit vagus nerve stimulation
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client with ascites is scheduled for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?
- A. Supine
- B. Left side-lying
- C. Right side-lying
- D. Upright position.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Mucosal barrier fortifiers are used in peptic ulcer disease management for which of the following indications?
- A. To inhibit mucus production
- B. To neutralize acid production
- C. To stimulate mucus production
- D. To stimulate hydrogen ion diffusion back into the mucosa
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine which body areas?
- A. Nail beds
- B. Skin on the back of the hand
- C. Hard palate of the mouth
- D. Soles of the feet
Correct Answer: C
Rationale: To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine the hard palate of the mouth. Jaundice is best assessed in the sclera; however, in dark-skinned patients, normal yellow pigmentation may be present in the sclera, making it difficult to detect jaundice. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. Cyanosis is best observed in the nail beds, not indicative of jaundice. While skin on the palm of the hand can indicate jaundice, the back of the hand is not a typical area for assessment. Jaundice can be assessed on the soles of the feet in dark-skinned patients, but it is better visualized in the hard palate for accurate evaluation.