A nurse is educating a patient who has an ileal conduit due to bladder cancer.
Which statement from the patient suggests that further instruction is needed?
I need to catheterize the stoma multiple times a day.
I will need to measure my stoma each week.
I will always have to wear a pouch.
I need to clean around the stoma with soap and water.
The Correct Answer is A
Choice A rationale:
The patient does not need to catheterize the stoma multiple times a day. An ileal conduit is a type of urostomy where a small piece of the intestine, called the ileum, is used to create a new passage for urine to leave the body. One end of the ileum is attached to the ureters, and the other end is attached to a small opening in the abdomen, known as a stoma. After the surgery, urine flows from the kidneys, through the ureters and ileal conduit, and out of the stoma. The patient will wear a urostomy pouching system over the stoma to catch and hold the urine. Therefore, the statement “I need to catheterize the stoma multiple times a day” suggests that further instruction is needed because it is not accurate.
Choice B rationale:
The statement “I will need to measure my stoma each week” does not necessarily suggest that further instruction is needed. It is important for patients with an ileal conduit to monitor their stoma regularly for any changes in size, shape, or color, which could indicate complications. However, the frequency of these checks can vary depending on the individual’s condition and the healthcare provider’s instructions.
Choice C rationale:
The statement “I will always have to wear a pouch” is accurate. After the surgery, the patient’s urine will flow from the kidneys, through the ureters and ileal conduit, and out of the stoma. The patient will need to wear a urostomy pouching system over the stoma to catch and hold the urine. Therefore, this statement does not suggest that further instruction is needed.
Choice D rationale:
The statement “I need to clean around the stoma with soap and water” is accurate. It is important for patients with an ileal conduit to keep the skin around the stoma clean to prevent infection and skin irritation. Therefore, this statement does not suggest that further instruction is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.
Choice B rationale:
After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.
Choice C rationale:
Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.
Choice D rationale:
Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.
Correct Answer is A
Explanation
Choice A rationale:
Circulatory overload, also known as hypervolemia or fluid overload, is a condition where the body has too much fluid. This excess fluid, especially in the circulatory system, can lead to a rapid heartbeat. This is because the heart needs to work harder to pump the increased volume of blood, leading to an increased heart rate.
Choice B rationale:
Weight loss is not typically associated with circulatory overload. In fact, quick weight gain might be observed due to the excess fluid in the body.
Choice C rationale:
Low blood pressure is not a common symptom of circulatory overload. On the contrary, high blood pressure can occur because the excess fluid in the circulatory system puts more pressure on the blood vessel walls.
Choice D rationale:
Excessive sweating is not a direct symptom of circulatory overload. However, symptoms such as shortness of breath and swelling in certain areas of the body are more common.
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