A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,

"My stoma size will stay the same, even after it has healed."

"My stoma will drain liquid fluid continuously."

"I will change my pouch system every 2 weeks."

"I will ensure that my medications are enteric coated."

Answer and Explanation

The Correct Answer is B

A. "My stoma size will stay the same, even after it has healed." - This statement is incorrect.

Stoma size can change during the healing process and may continue to evolve over time due to factors such as swelling, retraction, or prolapse.

B. "My stoma will drain liquid fluid continuously." - This statement is correct. In an ileostomy, the stoma typically drains liquid stool continuously due to the absence of the colon, which is responsible for absorbing water from the feces.

C. "I will change my pouch system every 2 weeks." - This statement is incorrect. The frequency of pouch changes depends on individual factors such as stoma size, type of pouching system used, and personal preference. It is essential to teach clients to change their pouch when needed, which may vary from a few days to a week or longer.

D. "I will ensure that my medications are enteric coated." - This statement is unrelated to ileostomy care. Enteric-coated medications are designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the alkaline environment of the small intestine. It is not directly relevant to stoma care.

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Correct Answer is A

Explanation

A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.

A. Hepatotoxicity B. Ototoxicity C. Hypercalcemia D. Hypertension

Correct Answer is B

Explanation

A. Vancomycin is not typically associated with hepatotoxicity.

B. Ototoxicity, which can manifest as hearing loss or tinnitus, is a potential adverse reaction of vancomycin therapy, especially with prolonged or high-dose therapy. Monitoring for signs of hearing impairment is essential.

C. Hypercalcemia is not a common adverse reaction associated with vancomycin therapy.

D. Hypertension is not a common adverse reaction associated with vancomycin therapy.

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A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Correct Answer is A

Explanation

A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

Correct Answer is B

Explanation

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