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 {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
A. It would not be appropriate to place the client on restraints as this would increase agitation and he is not violent.
B. The client may have a urinary tract infection (UTI) that is causing fever, hypotension, and confusion. Monitoring elimination can help assess the severity of the infection and the need for antibiotics.
C. Dimming the lights can help reduce sensory overload and agitation in the client.
Correct Answer is C
Explanation
A. Arterial blood gases - Arterial blood gases are not typically assessed before initiating lithium carbonate therapy.
B. Total cholesterol - Total cholesterol levels are not specifically relevant to monitoring lithium therapy.
C. Thyroid hormones - Thyroid function should be assessed before initiating lithium therapy because lithium can affect thyroid function, potentially leading to hypothyroidism.
D. Hemoglobin - While hemoglobin levels may be monitored during lithium therapy, they are not typically assessed prior to initiating treatment.
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