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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hepatitis A does not infect the kidneys. Hepatitis A is a viral infection that primarily affects the liver, causing inflammation.
B. Manifestations of hepatitis A are indeed similar to flu-like symptoms. Common symptoms include fever, fatigue, nausea, vomiting, abdominal pain, loss of appetite, and jaundice (yellowing of the skin and eyes).
C. The incubation period for hepatitis A is typically 15 to 50 days, not 5 days. The incubation period is the time between exposure to the virus and the onset of symptoms.
D. A family history is not a significant risk factor for acquiring hepatitis A. Hepatitis A is primarily transmitted through the fecal-oral route, often due to contaminated food or water. It is more commonly associated with exposure to the virus through contaminated environments or ingestion of contaminated food or water.
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.
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