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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Inserting an indwelling catheter involves an invasive procedure and assessment of urinary output and client status, which falls within the RN’s scope of practice in a high-risk client such as one with acute liver failure.
B. Obtaining abdominal girth requires assessment skills and interpretation for changes in ascites, which is more appropriate for the RN to ensure accurate monitoring.
C. Assessing and documenting level of consciousness is a critical assessment, especially in liver failure where hepatic encephalopathy is a risk. This is within the RN’s responsibility because changes can be subtle and require immediate intervention.
D. Measuring the amount of gastric drainage every 2 hours is a stable, routine task that follows established parameters and does not require advanced assessment skills. It is within the LPN’s scope and can be safely delegated, with the RN overseeing interpretation of any abnormal findings.
Correct Answer is B
Explanation
A. Herpes simplex virus (HSV) type 1 infection is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.
B. Hepatitis A is a reportable infectious disease to the CDC due to its potential for public health significance, particularly in outbreaks or clusters of cases.
C. Human papillomavirus (HPV) infection is not typically a reportable diagnosis to the CDC unless it is part of a larger study or surveillance effort.
D. Pediculosis capitis (head lice infestation) is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.
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