A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?
"I will empty my bag when it is full."
"I will take a laxative when I'm constipated."
"I will expect my stools to be loose."
"I will eat a high-fiber diet."
The Correct Answer is C
An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
The nurse's priority is to ensure that the client has given informed consent for the surgery, which requires that the client is competent and understands the risks and benefits of the procedure. A client with a high blood alcohol level may not have the mental capacity to consent and may need a legal representative or a court order to proceed with the surgery.
The other actions are important but not as urgent as obtaining consent.
Correct Answer is B
Explanation
Anemia is a condition characterized by a decrease in hemoglobin level or red blood cell count, resulting in reduced oxygen-carrying capacity of the blood. This can cause various symptoms such as fatigue, weakness, pallor, dyspnea, tachycardia, and headache.
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