A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

Change the ostomy pouch daily.

Empty the ostomy pouch when it is 2/3 full.

Trim the opening of the ostomy seal to be 1/2 inch wider than the stoma.

Apply lotion to the peristomal skin when changing the ostomy pouch.

Answer and Explanation

The Correct Answer is B

Choice A reason: Changing the ostomy pouch daily is not typically necessary. Most pouches can be worn comfortably for several days before needing to be changed. Frequent changes are not only unnecessary but can also irritate the skin around the stoma.

Choice B reason: Emptying the ostomy pouch when it is 2/3 full is recommended to prevent leaks and overfilling, which can lead to discomfort and potential skin irritation. It is important to monitor the fullness of the pouch and empty it regularly to maintain hygiene and comfort.

Choice C reason: Trimming the opening of the ostomy seal to be 1/2 inch wider than the stoma is incorrect. The opening should be cut to match the size of the stoma to ensure a snug fit that prevents leakage and protects the skin around the stoma.

Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not advised. Lotions or creams can interfere with the adhesive of the ostomy appliance and should be avoided. The peristomal skin should be clean and dry to ensure proper adhesion of the ostomy appliance.

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Correct Answer is B

Explanation

Choice A reason: While wearing gloves is a standard precaution to prevent contamination and protect the nurse from potential pathogens, the gloves used for collecting a guaiac smear sample do not need to be sterile. Clean, non-sterile gloves are typically sufficient for this procedure.

Choice B reason: It is crucial to discard any samples that contain urine because urine can interfere with the results of the fecal occult blood test (FOBT). The presence of urine can cause false positives due to the peroxidase activity in urine, which can lead to unnecessary further testing.

Choice C reason: Collecting three samples from a single bowel movement is not recommended. Instead, it is advised to collect samples from three separate bowel movements to increase the likelihood of detecting intermittent bleeding, which is common in conditions like colorectal cancer.

Choice D reason: Taking the sample from the outer edge of formed stool is not the best practice. The sample should be taken from different areas of the stool to ensure a representative sample, as blood may not be uniformly distributed throughout the stool.

A. Hypotension B. Increased temperature C. Lethargy D. Decreased heart rate

Correct Answer is B

Explanation

Choice A reason: Hypotension, or low blood pressure, is not typically associated with thyroid storm. Thyroid storm is a life-threatening condition that often presents with hypertensive crisis due to the excessive amount of thyroid hormones accelerating the body's metabolism.

Choice B reason: Increased temperature is a hallmark sign of thyroid storm. Patients experiencing a thyroid storm can have a high fever, with temperatures ranging from 104°F to 106°F. This is due to the hypermetabolic state induced by excessive thyroid hormones, which increases the body's heat production.

Choice C reason: Lethargy is not a common symptom of thyroid storm. Instead, patients may experience agitation, irritability, and anxiety due to the overstimulation of the nervous system by excessive thyroid hormones. Lethargy might be observed in hypothyroidism, which is the opposite condition.

Choice D reason: A decreased heart rate is not characteristic of thyroid storm. On the contrary, tachycardia, or a rapid heart rate, is a common symptom. The heart rate can exceed 140 beats per minute as the body's demand for oxygen increases due to the hypermetabolic state.

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A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

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