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","B","C"]
Explanation
Choice A rationale:
Spinach is one of the most nutrient-dense vegetables. Just 1 cup (190 grams) of frozen spinach packs 12% of the DV for potassium. It’s also loaded with other nutrients. The same serving of frozen spinach contains 127% of the DV for vitamin A, 857% for vitamin K, 58% for folate, and 37% for magnesium.
Choice B rationale:
Potatoes are a staple food and are high in potassium. They are a versatile and filling food that can be included in a variety of dishes. Potatoes are also a good source of vitamin C and dietary fiber.
Choice C rationale:
Bananas are known as potassium-rich foods. A medium banana contains around 9% of the DV for this mineral. Most people consider it the go-to food to increase their potassium intake. However, bananas are not the only good source of potassium.
Choice D rationale:
Apples are a healthy choice and provide some potassium, but they are not as high in potassium as the other choices. Therefore, while apples are a good part of a balanced diet, they would not be the first recommendation for someone needing to increase their potassium intake.
Correct Answer is B
Explanation
Choice A rationale:
A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.
Choice B rationale:
Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.
Choice C rationale:
A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.
Choice D rationale:
Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.
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