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 A
Explanation
Correct answer: A
A. Bear down:
Bear down: Asking the clientto bear down gently (as if to void) helps to expose urethral meatus.Bearing down simulates the act of urination and helps open the urethra.
B. Exhale slowly:
While exhaling slowly might help the client relax, it does not specifically assist with the insertion of the catheter as effectively as bearing down.
C. Contract the pelvic muscles:
Contracting the pelvic muscles (such as squeezing or tightening) might make catheter insertion more challenging by tensing the area where the catheter needs to pass through.
D. Take a sip of water:
Drinking water is not typically instructed during urinary catheter insertion, as it's unrelated to the process and might increase discomfort.
Correct Answer is A
Explanation
A. Obstruction of the bile duct:
Biliary cirrhosis can result from chronic obstruction of the bile ducts, leading to damage to the liver tissue. This obstruction can be due to various causes, such as gallstones or strictures.
B. Hepatotoxic medications:
While certain medications can contribute to liver damage, biliary cirrhosis specifically refers to conditions affecting the bile ducts. Hepatotoxic medications may contribute to cirrhosis but not necessarily biliary cirrhosis.
C. Hepatitis C:
Hepatitis C is a viral infection that primarily affects the liver. While chronic hepatitis C infection can lead to cirrhosis, it is not synonymous with biliary cirrhosis.
D. Excessive alcohol consumption:
Excessive alcohol consumption is a common cause of cirrhosis, but biliary cirrhosis specifically refers to cirrhosis resulting from chronic obstruction of the bile ducts.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today