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 B
Explanation
Choice A reason: Looping the tubing on the client's bed can cause kinks and obstruct the drainage, which is not
recommended.
Choice B reason: Taping the connections on the chest tube is essential to maintain an airtight system and prevent air leaks, which is crucial for proper chest tube function.
Choice C reason: The chest tube drainage system should be placed below the level of the client's heart to facilitate gravity drainage, not above.
Choice D reason: Stripping the chest tube, which involves squeezing and pulling the tubing to clear clots, is not routinely recommended as it can generate negative pressure and damage tissue.
Correct Answer is D
Explanation
Choice A reason: Evaluation is the final step of the nursing process, where the nurse assesses the client's response to the nursing interventions.
Choice B reason: Data Collection is the first step of the nursing process, where the nurse gathers information about the client's health status.
Choice C reason: Re-collection of Data may be necessary if there are changes in the client's condition, but it is not the immediate next step after planning.
Choice D reason: Implementation is the correct answer because it is the step where the nurse puts the care plan into action, following the planning step.
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