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 D

Explanation

A. Sputum culture is used to diagnose active tuberculosis but is not typically used for routine screening of asymptomatic individuals.

B. Chest x-ray can detect active tuberculosis or its complications but is not typically used for routine screening of asymptomatic individuals.

C. QuantiFERON-TB Gold blood analysis is a blood test that detects the presence of tuberculosis infection but is not typically used for routine screening of asymptomatic individuals.

D. The Mantoux test, also known as the tuberculin skin test (TST), is commonly used for routine screening of tuberculosis infection in asymptomatic individuals, including new employees in healthcare settings.

A. "Your PICC line will allow long-term access for antibiotic therapy." B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." C. "Your PICC line must be placed in your nondominant arm." D. "You should immobilize the arm with the PICC line using a sling."

Correct Answer is A

Explanation

A. "Your PICC line will allow long-term access for antibiotic therapy." - PICC lines are often used for long-term administration of medications, including antibiotics, due to their durability and ease of use.

B. "You should use a 5-milliliter barrel syringe to flush your PICC line at home." - The size of the syringe used to flush a PICC line depends on the facility's protocol and the client's specific

needs. Specific instructions regarding syringe size should be provided by the healthcare provider or nurse.

C. "Your PICC line must be placed in your nondominant arm." - The choice of arm for PICC line placement depends on various factors, including vein integrity and the client's comfort. There is no strict requirement for the PICC line to be placed in the nondominant arm.

D. "You should immobilize the arm with the PICC line using a sling." - Immobilizing the arm with a sling is not typically necessary after PICC line placement. Clients are usually instructed to avoid excessive movement and to keep the arm clean and dry to prevent complications.

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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 is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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