A nurse is developing a teaching plan for a client who has an Ileostomy and will require stoma care. Which of the following Information should the nurse include?

Clean the peristomal skin four times a day.

Hold pressure on the skin barrier for 10 to 15 sec to secure the seal.

Empty the pouch when it is 1/3 Full

Expect firm fecal content.

Answer and Explanation

The Correct Answer is C

A. Clean the peristomal skin four times a day:
While keeping the peristomal skin clean is essential, cleaning it four times a day might be excessive and could lead to skin irritation. Typically, cleansing the area when changing the pouch or as needed is sufficient.

B. Hold pressure on the skin barrier for 10 to 15 seconds to secure the seal:
Applying gentle pressure upon application can assist in securing the seal, but the duration might vary based on the manufacturer's recommendations. It's important not to overly press or manipulate the barrier excessively, as it could cause skin trauma.

C. Empty the pouch when it is 1/3 full:
This is the correct advice. Regularly emptying the pouch prevents leakage and ensures the pouch does not become too heavy or cause skin irritation from weight or pressure.

D. Expect firm fecal content:
With an ileostomy, the fecal content tends to be more liquid compared to other types of ostomies like colostomies, so expecting firm fecal content might not be accurate for this situation.

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Correct Answer is C

Explanation

A. "Wear compression stockings daily":

Compression stockings are not directly related to preventing the complications of retinopathy and nephropathy in diabetes. They are more commonly recommended for managing conditions like venous insufficiency and preventing blood clots.

B. "Have an eye examination once per year":

While regular eye examinations are important for monitoring and early detection of diabetic retinopathy, maintaining stable blood glucose levels is more directly related to preventing the progression of retinopathy.

C. "Maintain stable blood glucose levels":

This is the correct instruction. Stable blood glucose levels are crucial in preventing and minimizing the long-term complications of diabetes, including retinopathy (damage to the retina) and nephropathy (kidney damage). Consistent blood glucose control is key to reducing the risk of complications.

D. "Examine your feet carefully every day":

Daily foot examinations are essential for preventing diabetic foot complications, including ulcers and infections. While important for overall diabetes management, foot care is not specifically directed at preventing retinopathy and nephropathy.

A. Apply a cold pack to the client's upper arm. B. Remove the PICC line. C. Notify the provider who inserted the PICC line. D. Stop the infusion and measure the circumference of both upper arms.

Correct Answer is D

Explanation

A. Applying a cold pack to the client's upper arm is not the first action. The priority is to assess and address the cause of the edema. Cold packs may be used for comfort, but they do not address the underlying issue.

B. Removing the PICC line is not the first action. Before considering removal, it is essential to assess the extent and cause of the edema. Removing the line without proper evaluation could lead to premature discontinuation of necessary treatment.

C. Notifying the provider who inserted the PICC line is important, but it is not the first action. The nurse needs to assess and intervene promptly. The provider should be informed after initial actions are taken.

D. Stopping the infusion and measuring the circumference of both upper arms is the first action. This helps determine the extent of the edema and whether it is related to the infusion. It is crucial to assess for complications such as infiltration or extravasation of the TPN solution.

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A nurse is developing a teaching plan for a client who has an Ileostomy and will require stoma care. Which of the following Information should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching an older adult client diagnosed with diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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