A nurse is assisting with evaluating a newly licensed nurse who is draining an ileostomy bag for a client. Which of the
following actions by the newly licensed nurse indicates an understanding of the procedure?
Wears sterile gloves to drain the ileostomy bag
Washes the skin surrounding the client's ileostomy with hot water
Cleans the end of the ileostomy pouch before clamping
Empties the ileostomy bag when it is three-fourths full
The Correct Answer is C
Choice A reason: Wearing sterile gloves is not necessary when draining an ileostomy bag as this is not a sterile procedure. Clean gloves are typically used.
Choice B reason: Washing the skin surrounding the ileostomy with hot water is not recommended as it can cause
irritation. Lukewarm water should be used, and the area should be patted dry.
Choice C reason: Cleaning the end of the ileostomy pouch before clamping is important to maintain hygiene and
prevent contamination when draining the bag.
Choice D reason: The ileostomy bag should be emptied when it is one-third to one-half full to prevent leakage and ensure comfort for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Aspirating fluid from the IV cannula is not recommended as it does not address the issue of infiltration or extravasation.
Choice B reason: Placing the affected extremity below the level of the client's heart could worsen the swelling and is
not recommended.
Choice C reason: Slowing the IV infusion is a correct immediate action to minimize further infiltration and should be done while further assessment and interventions are planned.
Choice D reason: Placing a pressure dressing over the IV site is not recommended as it may exacerbate the infiltration
and increase discomfort.
Correct Answer is A
Explanation
Choice A reason: With aging, there is a slight slowing in the movement of contents through the large intestine and a modest decrease in the contractions of the rectum when filled with stool, leading to decreased intestinal peristalsis.
Choice B reason: Aging does not typically result in a decreased pH of the stomach. Instead, conditions that decrease acid secretion, such as atrophic gastritis, become more common with age.
Choice C reason: Increased muscle tone of the bowel is not a change associated with aging. In fact, muscle tone may decrease, contributing to issues such as constipation.
Choice D reason: Increased gastric acid production is not a typical physiological change with aging. The secretion of stomach juices such as acid and pepsin has little effect on aging, although conditions that decrease acid secretion become more common.
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