A client diagnosed with ulcerative colitis has a new ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy?
"I should clean the stoma site with warm water and mild soap."
"I can continue to participate in physical activities and exercise."
"I should avoid eating high-fiber foods."
"I should change the ostomy bag every day."
The Correct Answer is D
A. Cleaning the stoma site with warm water and mild soap is appropriate and the correct way to maintain stoma hygiene. No harsh chemicals or abrasive materials should be used.
B. It is safe for the client to continue participating in physical activities and exercise, as long as they feel comfortable and take necessary precautions to protect the stoma.
C. Clients with an ileostomy are generally advised to avoid high-fiber foods, especially right after surgery, to reduce the risk of blockages.
D. The ostomy bag should typically be changed every 3 to 7 days, depending on the type of bag used and the amount of output. Changing it every day is unnecessary unless there are signs of leakage or skin irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reviewing electrolyte values is the first action to take, as clients with acute exacerbations of ulcerative colitis are at risk for electrolyte imbalances due to diarrhea and fluid loss. It is essential to correct any imbalances promptly to avoid complications like cardiac arrhythmias.
B. While obtaining a dietary history is important to understand the client's eating habits and trigger foods, it is not the priority when the client is experiencing an acute exacerbation. Addressing immediate physiological needs comes first.
C. Checking perianal skin integrity is important, as diarrhea and frequent bowel movements can lead to irritation or breakdown of the skin, but this is not the first priority in the acute phase of exacerbation. Managing electrolyte levels and hydration takes precedence.
D. Investigating emotional concerns is important in the holistic care of the patient, but it is not the first priority in managing an acute exacerbation of ulcerative colitis. Ensuring the client is physically stable through electrolyte management is more urgent.
Correct Answer is B
Explanation
A. While assessing sputum is important to determine its color, consistency, and amount, it is not the priority before performing percussion, vibration, and postural drainage. The nurse should first assess the patient's overall respiratory status.
B. Assessing pulse and respirations is the first step in ensuring the patient's baseline respiratory status is stable before performing respiratory therapies. This allows the nurse to detect any signs of distress or abnormal respiratory patterns, which could indicate the need for further intervention before the procedure.
C. Auscultating lung fields is important for evaluating the effectiveness of the percussion and drainage procedure, but the initial assessment should include vital signs, such as pulse and respirations, to ensure the patient is stable.
D. Instructing the patient to slowly exhale with pursed lips is a helpful technique for managing respiratory distress, but it is not the first priority before conducting percussion or postural drainage. The nurse should first assess vital signs.
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