A nurse is providing discharge teaching for a client who had a partial colectomy 2 days ago. Which of the following information should the nurse include in the teaching?

"Place an aspirin in your ostomy pouch to control odor."

"Your ostomy should start functioning in five days."

"Empty your ostomy pouch when it becomes a third to halfway full."

"Notify your provider if your stoma becomes dark red:"

Answer and Explanation

The Correct Answer is C

A. "Place an aspirin in your ostomy pouch to control odor.": Aspirin should never be placed in an ostomy pouch, as it can damage the pouch material and irritate the stoma. Deodorizers or dietary adjustments are safer alternatives for odor control.

B. "Your ostomy should start functioning in five days.": An ostomy typically begins functioning within 2 to 4 days postoperatively, depending on bowel motility. Waiting five days without output could indicate an obstruction or ileus, requiring medical evaluation.

C. "Empty your ostomy pouch when it becomes a third to halfway full.": Keeping the pouch from becoming too full prevents leaks, discomfort, and excessive pressure on the stoma. This practice helps maintain skin integrity and ostomy function.

D. "Notify your provider if your stoma becomes dark red.": A dark red stoma is normal and indicates good blood supply. However, a stoma that turns pale, dusky, or black requires immediate medical attention, as it suggests compromised circulation and possible necrosis.

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Correct Answer is D

Explanation

A. "Use the incentive spirometer every 4 hours.": Incentive spirometry is typically recommended every 1 to 2 hours while awake to promote lung expansion and prevent atelectasis. Less frequent use may not provide adequate lung re-expansion, especially after surgery.

B. "Avoid coughing during and after the session.": Coughing is encouraged after using an incentive spirometer to help clear secretions and prevent respiratory complications such as pneumonia. Suppressing a cough can lead to mucus retention and increased risk of infection.

C. "Remove the mouthpiece and exhale quickly.": The client should exhale normally before using the spirometer, then inhale slowly through the mouthpiece to maximize lung expansion. Rapid exhalation does not promote adequate alveolar inflation.

D. "Place the mouthpiece in your mouth and inhale slowly.": Slow, deep inhalation through the spirometer allows for maximum lung expansion, reducing the risk of atelectasis. The client should maintain a steady breath to ensure optimal lung inflation and hold it for a few seconds before exhaling.

A. Insert a urinary catheter. B. Prepare the client for an intravenous pyelogram. C. Administer IV fluids to the client. D. Initiate beta blocker therapy.

Correct Answer is C

Explanation

A. Insert a urinary catheter: While a urinary catheter may be necessary for monitoring urine output, it does not directly prevent acute kidney failure. Maintaining adequate perfusion and hydration is the primary concern in preventing kidney injury.

B. Prepare the client for an intravenous pyelogram: An intravenous pyelogram (IVP) involves contrast dye, which can be nephrotoxic and potentially worsen kidney function. It is not appropriate in a client at risk for acute kidney injury.

C. Administer IV fluids to the client: Fluid resuscitation helps maintain adequate renal perfusion and prevents hypovolemia-induced acute kidney failure. Clients with significant blood loss are at high risk for prerenal kidney injury due to decreased perfusion.

D. Initiate beta blocker therapy: Beta blockers are used for cardiovascular conditions but do not prevent acute kidney failure. In this situation, maintaining blood volume and renal perfusion is the priority.

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A nurse is providing discharge teaching for a client who had a partial colectomy 2 days ago. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

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