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. Wearing an N95 respirator is not necessary when caring for a client with neutropenia due to HIV unless the client has respiratory symptoms or is undergoing procedures that generate aerosols.
B. Inserting an indwelling urinary catheter should be avoided unless necessary, as it can
introduce the risk of infection, which is particularly concerning in clients with neutropenia.
C. Monitoring vital signs every 8 hours may not provide sufficient frequency for detecting changes in a client with neutropenia who may be at risk for rapid deterioration.
D. Using a dedicated stethoscope helps prevent the spread of infection to other clients by avoiding cross-contamination, which is especially important when caring for a client with neutropenia who is at increased risk of infection.
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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