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 C
Explanation
A. Calcium:
While calcium levels can be affected in pancreatitis, it is more commonly associated with a decrease in calcium levels due to fat necrosis and the formation of calcium soaps. However, the primary electrolyte disturbance is more likely to involve magnesium.
B. Magnesium:
Magnesium levels may be decreased in acute pancreatitis due to factors such as vomiting, malabsorption, and poor oral intake. Hypomagnesemia is a possible consequence, but it's not as specific to pancreatitis as the elevation of amylase.
C. Amylase:
Elevated amylase levels are a hallmark of acute pancreatitis. Amylase is an enzyme released by the pancreas, and its elevation in the blood is a key diagnostic marker for pancreatitis.
D. RBC count:
Acute pancreatitis does not typically result in a significant impact on the red blood cell (RBC) count. The elevation of amylase and lipase levels, along with imaging studies, is more indicative of pancreatitis.
Correct Answer is ["A","B","C","D"]
Explanation
A. Increase physical activity and daily exercise.
Regular physical activity helps improve insulin sensitivity, manage blood glucose levels, and lower the risk of cardiovascular complications associated with diabetes.
B. Reduce cholesterol and saturated fat intake.
Managing cholesterol levels and reducing saturated fat intake can help lower the risk of cardiovascular disease, which is a common complication of diabetes.
C. Maintain optimal blood pressure to prevent kidney damage.
Controlling and maintaining blood pressure within optimal ranges is crucial in preventing kidney damage, a common complication of diabetes.
D. Enroll in a smoking-cessation program.
Smoking increases the risk of cardiovascular complications and can exacerbate other diabetes-related health issues. Quitting smoking is important in reducing the risk of complications.
E. Sustain hyperglycemia to reduce deterioration of nerve cells.
Sustaining hyperglycemia (high blood sugar levels) is detrimental and contributes to the progression of diabetic complications, including nerve damage (neuropathy). Lowering and controlling blood glucose levels are essential in preventing complications rather than sustaining hyperglycemia.
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