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 A
Explanation
Choice A rationale:
Caffeinated beverages are known to cause diarrhea. Caffeine naturally occurs in many foods and drinks, including coffee and chocolate. It speeds up the digestive system and can cause loose stools. In addition, caffeine can irritate the stomach lining during digestion. Therefore, it’s important for the nurse to educate the patient about the potential effects of caffeinated beverages on their digestive system.
Choice B rationale:
Low-fiber cereal is not typically associated with triggering diarrhea. In fact, foods that are low in fiber can actually help firm up stools and are often recommended for individuals experiencing diarrhea. Therefore, while it’s not harmful, it’s not a primary concern for patients with diarrhea.
Choice C rationale:
White rice is another food that does not typically cause diarrhea. Similar to low-fiber cereal, white rice can help firm up stools and is often recommended for individuals experiencing diarrhea. It’s not a primary concern for patients with diarrhea.
Choice D rationale:
Ripe bananas do not typically cause diarrhea. They are actually part of the BRAT diet (Bananas, Rice, Applesauce, Toast), which is often recommended for individuals experiencing diarrhea. Therefore, it’s not a primary concern for patients with diarrhea.
In conclusion, when educating a patient about food and drinks that can trigger diarrhea, the nurse should include caffeinated beverages as they can potentially cause diarrhea. However, low-fiber cereal, white rice, and ripe bananas are not typically associated with triggering diarrhea.
Correct Answer is C
Explanation
Choice A rationale:
Wheezing Wheezing is typically associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), rather than being a symptom of hyperkalemia.
Choice B rationale:
Cerebral edema Cerebral edema, or swelling in the brain, is not typically a symptom of hyperkalemia. It’s more commonly associated with traumatic brain injury, stroke, or brain tumors.
Choice C rationale:
Decreased deep tendon reflexes Decreased deep tendon reflexes can be a symptom of hyperkalemia. Hyperkalemia is a condition in which the potassium levels in your blood get too high. Potassium helps nerves send signals between your brain and the rest of your body. High levels of potassium can affect nerve function, leading to symptoms such as muscle weakness or decreased reflexes. Choice D rationale:
Hypoactive bowel sounds Hypoactive bowel sounds, or decreased or absent bowel sounds, are typically associated with conditions affecting the gastrointestinal system, such as ileus or bowel obstruction. They are not typically a symptom of hyperkalemia.
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