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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Testing the client's emesis for blood is an important assessment, but assessing orthostatic blood pressure is a priority. Orthostatic blood pressure measurement helps identify if the client is experiencing significant blood loss, as changes in blood pressure upon standing may indicate hypovolemia.
B. Assessing orthostatic blood pressure is the priority action. Orthostatic hypotension can be a sign of decreased circulating blood volume, which is a concern in clients with gastrointestinal bleeding.
C. Explaining the procedure for an upper gastrointestinal series is not the first priority. While diagnostic tests may be needed, addressing the immediate concern of potential hypovolemia takes precedence.
D. Administering pain medication is not the first action. The priority is to assess and address the potential complications of gastrointestinal bleeding, such as hypovolemia.
Correct Answer is B
Explanation
A. "A weight reduction program will make me hypoglycemic.”
This statement suggests a misunderstanding. Weight reduction programs, when done appropriately, can contribute to better blood sugar control, but they should not necessarily lead to hypoglycemia if managed properly.
B. "I give the insulin injections in my abdominal area.”
This is the correct statement. Injecting insulin into the abdominal area is a common and recommended practice as it allows for consistent absorption and is a well-vascularized area.
C. “Insulin allows me to eat ice cream at bedtime.”
This statement suggests a misunderstanding. While insulin helps manage blood sugar levels, it should not be seen as a means to consume unlimited quantities of high-sugar foods, as a balanced diet is still crucial.
D. "I am to take my blood sugar reading after meals.”
This statement is partially correct. Blood sugar readings are often recommended before and after meals to assess the impact of food intake on blood glucose levels.
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