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 C

Explanation

A. Notifying the facility operator is important, but it is not the immediate priority when there is a fire endangering the client's safety.

B. While closing fire doors can help contain the fire, it is not the priority action after ensuring the client's immediate safety.

C. Turning off oxygen sources is crucial because oxygen can fuel the fire and cause it to spread rapidly. This action helps prevent the fire from worsening.

D. Putting out the fire with the appropriate extinguisher is important, but it comes after ensuring the fire's fuel source is cut off to prevent further escalation of the fire.

A. Restrict dietary calcium intake. B. Limit fluid intake to 40 oz/day. C. Decrease complex carbohydrates in the diet. D. Avoid foods that have high levels of oxalates.

Correct Answer is D

Explanation

A. Restricting dietary calcium intake is not typically recommended for preventing nephrolithiasis; in fact, adequate calcium intake may decrease the risk of kidney stone formation.

B. Limiting fluid intake is not recommended for individuals with nephrolithiasis; adequate fluid intake helps prevent kidney stone formation.

C. Complex carbohydrates do not significantly impact the risk of nephrolithiasis; dietary changes should focus on other factors such as oxalate intake.

D. Foods high in oxalates, such as spinach, beets, nuts, and chocolate, can contribute to the formation of kidney stones in susceptible individuals, so it's important to avoid them.

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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 notices smoke coming from a client's room and discovers a fire in the wastebasket.After moving the client to safety, which of the following is the priority action?

Correct Answer is C

Explanation

A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching?

Correct Answer is D

Explanation

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