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 C
Explanation
A. "Rub your child's gums with an aspirin tablet before bedtime." - Aspirin is not recommended for children due to the risk of Reye's syndrome, a potentially fatal condition.
B. "Place an amber teething necklace on your child before bedtime." - Amber teething necklaces pose a choking hazard and are not recommended for infants.
C. "Administer acetaminophen drops to your child before bedtime." - Acetaminophen is a safe and effective pain reliever for infants and can help alleviate discomfort associated with teething, which may improve sleep.
D. "Apply a teething product containing benzocaine to your child's gums before bedtime." -
Benzocaine-containing products are not recommended for infants due to the risk of methemoglobinemia, a potentially life-threatening condition.
Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}
Explanation
A. To best hear the closing of the aortic heart valve, the nurse should place the diaphragm of the stethoscope at the second intercostal space, right sternal border. This is also known as the aortic area.
B. This is the tricuspid region, and defects with the tricuspid valve will be best heard in this area.
C. This is the mitral region and murmurs due to defects in the mitral valve will be appreciated here
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