A nurse is reinforcing teaching about ileostomy care with a client. The nurse should recognize which of the following statements by the client indicates a need for further teaching?

"I will be certain to take enteric-coated medications."

"I will empty my pouch when it becomes one third full."

"I will change my entire pouch system at least weekly."

"I will use caution when eating high fiber foods."

Answer and Explanation

The Correct Answer is A

A.   Enteric-coated medications are designed to dissolve in the small intestine rather than the stomach. This is important for ileostomy patients because medications that dissolve in the stomach may be poorly absorbed or can cause irritation to the stoma or the small intestine.
B.   It's recommended to empty the ostomy pouch when it's about one-third to half full to prevent leakage or discomfort.
C.   How often the pouch system needs to be changed can vary depending on individual factors such as skin sensitivity, output consistency, and the type of pouch system used. Generally, changing the pouch system every 3-7 days is recommended.
D.   High fiber foods can increase stool output and gas production, which can be challenging for individuals with an ileostomy. However, fiber is important for overall digestive health, so moderation rather than avoidance is typically recommended.

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Correct Answer is ["93.75"]

Explanation

Infusion rate (mL/hr)= Total volume (mL)/Total time (hr) 750 mL divided by 8 hours equals 93.75 mL/hr
Therefore, the nurse should set the IV pump at 94Ml/HR

A. Provide mouth care. B. Auscultate lung fields. C. Position the client so that the lung area to be drained is above the client's trachea. D. Cup hands and tap on the client's chest repeatedly.

Correct Answer is B

Explanation

A. Mouth care is an important aspect of overall care, but it is not directly related to chest percussion, vibration, and postural drainage. It can be done before or after these procedures as needed for client comfort and oral hygiene.
B. Auscultating the lung fields is a crucial step before initiating chest percussion, vibration, and postural drainage. It helps the nurse assess the current status of lung sounds, identify areas of congestion or consolidation, and determine the appropriate areas for percussion and drainage.
C. Positioning the client correctly is essential to facilitate effective drainage. By positioning the lung area to be drained above the trachea, gravity assists in moving secretions towards the larger airways for removal.
D. Chest percussion involves rhythmically tapping the chest wall with cupped hands to loosen and mobilize secretions in the lungs. This action helps to facilitate drainage during postural drainage.

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A nurse is reinforcing teaching about ileostomy care with a client. The nurse should recognize which of the following statements by the client indicates a need for further teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 0.9% sodium chloride (NaCl) 750 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["93.75"]

Explanation

A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?

Correct Answer is B

Explanation

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