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NUR 2571 Gastrointestinal - exam 1 notes
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NUR2571 Gastrointestinal - exam 1 notes T-Tube NCLEX Questions for Nursing Care
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lOMoARcPSD|3013804Gastrointestinal - exam 1
notes
Professional Nursing 2 (Rasmussen
University)
, lOMoARcPSD|3013804
GASTROINTESTINAL
T-Tube NCLEX Questions for Nursing Care
1. A patient had a cholecystectomy and has a t-tube in place. You’re helping the
nursing student understand how to care for the t-tube. The nursing student asks you where the
t-tube is located in the body. Your response is the:
A. Cystic duct
B. Hepatic duct
C. Bile duct
D. Pancreatic duct
The answer is C. The t-tube is located in the bile duct. It will serve as a drain to help
remove bile from the liver until the common bile duct is healed.
2. The nurse helps the patient with a t-tube get up from the bed and sit in the bedside
chair. Where will the nurse make it priority to position the tubing and drainage bag of the t-tube?
A. Slightly elevated above the t-tube insertion site
B. At heart level
C. Midline with the t-tube insertion site
D. At or below the waist
The answer is D. The t-tube drainage bag and tubing will work with the assistance of
gravity to drain the bile. Therefore, the tubing and drainage bag should be below the t-tube
insertion site (which is at or below the waist) to help drain bile.
3. Which position is best for a patient with a t-tube?
, lOMoARcPSD|3013804
GASTROINTESTINAL
A. Supine
B. Semi-Fowler’s
C. Right lateral recumbent
D. Left lateral recumbent
The answer is B. To help facilitate drainage (remember in order for the t-tube to work it
needs the assistance of gravity), positioning the patient at about 30-45 degrees (the Semi-
Fowler’s position) will be the best.
4. A patient is post-op day 4 from a t-tube placement. Which finding below requires
you to notify the physician?
A. Drainage from the t-tube is yellowish green.
B. Drainage from the t-tube within the past 24 hours is approximately 925 cc.
C. Blood tinged drainage from the t-tube has decreased.
D. Patient reports a decrease in nausea.
The answer is B. A drainage amount of 500 cc or more within a 24 hour period is
abnormal and the physician should be notified. On post-op day 4 the drainage should be
decreasing (NOT increasing). It is normal for the drainage to be yellowish green. Also blood
tinged drainage will decrease in the t-tube at this time (fresh post-op like day 1-2 it may be
blood tinged but this will decrease over time). The patient reporting a decrease in nausea is a
positive sign.
, lOMoARcPSD|3013804
GASTROINTESTINAL
5. The physician orders a patient’s t-tube to be clamped 1 hour before and 1 hour after
meals. You clamp the t-tube as prescribed. While the tube is clamped which finding requires
immediate nursing intervention?
A. The t-tube is not draining.
B. The t-tube tubing is below the patient’s waist.
C. The patient reports nausea and abdominal pain.
D. The patient’s stool is brown and formed.
The answer is C. A nurse should ONLY clamp a t-tube with a physician’s order. Most
physicians will prescribe to clamp the t-tube 1 hour before and 1 hour after meals. WHY? So,
bile will flow down into the small intestine (instead out of the body) during times when food is in
the small intestine to help with the digestion of fats. This is to help the small intestine adjust to
the flow of bile in preparation for the removal of the t-tube (remember normally it received bile
when the gallbladder contracted but now it will flow from the liver to the small intestine
continuously). Option C is an abnormal finding. The patient should not report nausea or
abdominal pain when the tube is blocked. This could indicate a serious problem. Option A is
correct because the t-tube should not be draining because it’s clamped. Option B is correct
because the t-tube tubing should be below or at the patient’s waist level. Option D is correct
because this shows the body is digesting fats and bilirubin is exiting the body through the stool
(remember bilirubin is found in the bile and gives stool its brown color…it would be light
colored if the bilirubin was not present). You would NOT want to see steatorrhea (fat/greasy
liquid stools) because this shows the bile isn’t being delivered to help digest the fats.
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