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. Level of consciousness:
While assessing the client's level of consciousness is important, it is not the top priority after an EGD procedure unless there are specific signs of neurological distress. Monitoring for signs of sedation or anesthesia recovery is typically part of post-procedure care.
B. Gag reflex:
This is the correct answer. The nurse should prioritize assessing the gag reflex, as the procedure involves passing a flexible tube through the mouth and down the esophagus. Ensuring the return of the gag reflex is essential to prevent aspiration and ensure the client's safety.
C. Pain:
Pain assessment is important, but it is usually addressed after confirming airway protection and ensuring the absence of complications such as bleeding or perforation.
D. Nausea:
While nausea is a possible post-procedure symptom, assessing the gag reflex and monitoring for signs of complications take precedence over managing nausea in the immediate post-procedure period.
Correct Answer is A
Explanation
A. Avoid foods high in fat:
Dietary fat can trigger the gallbladder to release bile, and for individuals with chronic cholecystitis, high-fat meals can exacerbate symptoms such as biliary colic. Therefore, advising the client to avoid foods high in fat can help manage symptoms.
B. Include foods high in starch and proteins:
While protein-rich foods can be included in the diet, a high-fat content should be avoided. Starches can be a part of a balanced diet, but it's essential to focus on low-fat options.
C. Include foods high in fiber:
Including foods high in fiber is generally a good recommendation for digestive health. However, the emphasis here is on avoiding high-fat foods, and the recommendation for fiber should not overshadow the importance of minimizing dietary fat.
D. Avoid foods high in sodium:
Sodium restriction may be relevant for certain health conditions, but it is not the primary dietary consideration for managing chronic cholecystitis. The emphasis in this context is on reducing dietary fat.
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