A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction?
"I should never attempt to reach into my stoma to remove fecal material."
"Using warm enema will reduce cramping and discomfort during the procedure."
"To properly irrigate and clean my ostomy stoma, I can use any solution that is convenient."
"Sitting on the toilet lets the ostomy bag and irrigant drain into the toilet bowl."
The Correct Answer is C
Choice A This statement is correct, as patients should never attempt to insert anything into the stoma to remove fecal material.
Choice B This statement is also correct, as using warm water for irrigation can help reduce discomfort and cramping during the procedure.
Choice C This statement is incorrect. Patients should use only the irrigation solution recommended by their healthcare provider, as using the wrong solution can lead to complications or damage to the stoma.
Choice D This statement is correct, as sitting on the toilet allows the ostomy bag and irrigation solution to drain directly into the toilet, making the procedure more convenient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A This change in blood pressure is not alarming and does not require immediate cessation of the procedure.
Choice B A slight increase in temperature is within a normal range and does not indicate an urgent issue related to the stool removal procedure.
Choice C A significant decrease in pulse rate suggests bradycardia, which can be a serious sign and might be caused by the stimulation of the vagus nerve during the procedure. The nurse should stop immediately and take corrective action.
Choice D An increase in respiratory rate may indicate increased anxiety or discomfort, but it is not an immediate cause for stopping the procedure.
Correct Answer is A
Explanation
Choice A This is considered a normal abdominal assessment. The abdomen is soft and not distended, and bowel sounds are present and normal in all four quadrants.
Choice B Abdominal distension and firmness may indicate possible bowel obstruction or other gastrointestinal issues. Hypoactive bowel sounds suggest reduced motility, which is not normal.
Choice C Abdominal distension with hyperactive bowel sounds may indicate gastrointestinal irritation or increased motility, which is not normal.
Choice D A firm abdomen with hypoactive bowel sounds is not typical of a normal abdominal assessment.
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