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 ["B","D","E"]

Explanation

A. The provider should renew the prescription for restraints every 24 hours, not 48 hours.
B. Padding bony prominences helps prevent skin breakdown and pressure injuries.
C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in an emergency.
D. Removing the restraints every 2 hours allows for circulatory assessment, skin care, and range of motion exercises.
E. The provider's prescription should specify the type of restraint to ensure proper and appropriate use.

A. "Limit your meals to three times per day." B. "Consume at least 25 grams of fiber daily." C. "Start each meal with a protein source." D. "Check your blood glucose level before each meal."

Correct Answer is C

Explanation

A. "Limit your meals to three times per day." - Incorrect. Following gastric bypass surgery,

clients are typically advised to eat small, frequent meals rather than limiting to three large meals per day.

B. "Consume at least 25 grams of fiber daily." - Incorrect. While fiber is important for gastrointestinal health, clients following gastric bypass surgery may need to avoid high-fiber foods initially and gradually reintroduce them based on individual tolerance.

C. "Start each meal with a protein source." - Correct. Protein is essential for wound healing and maintenance of muscle mass after gastric bypass surgery. Starting each meal with a protein source helps ensure an adequate intake.

D. "Check your blood glucose level before each meal." - This instruction is not directly related to dietary management following gastric bypass surgery. Blood glucose monitoring may be necessary for clients with diabetes, but it is not specific to post-gastric bypass dietary

instructions.

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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 manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge?

Correct Answer is C

Explanation

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