A nurse is performing discharge teaching with a client about the care of a newly created ileal conduit. The nurse should instruct the client to empty the appliance:
Daily at bedtime.
Twice a day.
When the bag is full.
When the bag is 2/3 full.
The Correct Answer is D
Choice A reason: Emptying the appliance daily at bedtime is not frequent enough to prevent leakage and ensure comfort, especially if the bag fills up during the day or night.
Choice B reason: Emptying the appliance twice a day may not be sufficient, depending on the amount of urine output. It could lead to overfilling and leakage.
Choice C reason: Waiting until the bag is full can increase the risk of leakage and discomfort. It is essential to empty the bag before it gets too full.
Choice D reason: Emptying the appliance when it is 2/3 full is the recommended practice. This prevents overfilling, reduces the risk of leakage, and ensures the client's comfort and hygiene.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increased glomerular filtration rate (GFR) would indicate improved kidney function, which is not expected in the oliguric phase of acute kidney injury. Instead, GFR is typically reduced during this phase.
Choice B reason: Decreased creatinine level suggests better kidney function and is not consistent with acute kidney injury, where creatinine levels are usually elevated due to impaired filtration.
Choice C reason: Hypomagnesemia, or low magnesium levels, is not a typical finding in acute kidney injury. Electrolyte imbalances more commonly include elevated levels of potassium and phosphorus.
Choice D reason: Hyperkalemia, or elevated potassium levels, is a common finding in the oliguric phase of acute kidney injury due to the kidneys' inability to excrete potassium effectively. This can lead to serious complications such as cardiac arrhythmias.
Correct Answer is A
Explanation
Choice A reason: Impaired skin integrity is a significant risk due to the constant exposure of the skin around the stoma to urine, which can lead to irritation and breakdown. Proper skin care and stoma care are essential to prevent complications.
Choice B reason: Disturbed body image is also a risk as the client adjusts to the physical changes and the presence of a stoma, which can impact self-esteem and body perception.
Choice C reason: Fluid volume deficit can occur if the client does not maintain adequate fluid intake or if there is significant leakage from the stoma. Monitoring fluid balance is crucial.
Choice D reason: Anxiety is common as clients adapt to managing a new ostomy, worrying about potential complications, and coping with changes in body function.
Choice E reason: Infection is a risk due to the exposure of the stoma and surrounding skin to bacteria from the urine. Proper hygiene and care are vital to prevent infections.
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