A nurse is assisting with teaching a client who is preoperative for an ileostomy. Which of the following statements
should the nurse include?
"You should expect your stoma to be a purple color."
"The end of the stoma will be painful after this procedure."
"You will have a stoma placed in your right lower abdomen."
"You will have solid stool pass through your stoma."
The Correct Answer is C
The correct answer is c. "You will have a stoma placed in your right lower abdomen."
Choice A reason: The stoma should appear red and moist, similar to the inside of the mouth, not purple.
Choice B reason: The stoma does not have nerve endings, so it should not be painful.
Choice C reason: An ileostomy is typically placed in the right lower abdomen.
Choice D reason: Stool passing through an ileostomy is usually liquid to pasty, not solid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Infusing 0.9% sodium chloride is not the immediate action to take when a transfusion reaction is suspected. The priority is to stop the transfusion and address the reaction.
Choice B reason: Obtaining a blood sample from the client is necessary to perform laboratory tests to confirm the transfusion reaction and to identify the cause.
Choice C reason: Returning the unit of blood to the blood bank is done after the transfusion has been stopped and the reaction has been addressed. It is important for the blood bank to know about the reaction to investigate the cause.
Choice D reason: Notifying the charge nurse is important, but the first action should be to stop the transfusion and maintain the client's safety. The charge nurse can then assist with the subsequent steps.
Correct Answer is A
Explanation
Choice A reason: Tachycardia, or an abnormally rapid heart rate, is a common finding in circulatory overload due to
the increased volume of blood the heart must pump.
Choice B reason: Weight loss is not typically associated with circulatory overload. In fact, weight gain may occur due
to fluid retention.
Choice C reason: Diaphoresis, or excessive sweating, can be associated with circulatory overload as the body attempts to cool down due to the increased blood volume and workload on the heart.
Choice D reason: Hypotension, or low blood pressure, is not a usual finding in circulatory overload. Instead, hypertension may be more likely due to the increased volume of fluid in the blood vessels.
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