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 A

Explanation

A. The oral mucosa, especially the lips and tongue, is a reliable indicator of central cyanosis. Cyanosis is evident as bluish discoloration in these areas due to the presence of deoxygenated hemoglobin.
B. Cyanosis is less reliably visible on the eyelids compared to the lips and oral mucosa. Skin over the eyelids is typically thinner, but detection of cyanosis here can be more challenging due to variations in skin pigmentation and thickness.
C. Similar to the eyelids, cyanosis may be less evident on the ear lobes compared to the lips and oral mucosa. Ear lobes are less vascular and may not consistently show cyanosis unless the condition is severe.
D. The tip of the nose is another area where cyanosis can be detected, although it is less reliable than the lips and oral mucosa. Like the eyelids and ear lobes, the detection of cyanosis here can vary depending on individual skin characteristics.

Correct Answer is ["100"]

Explanation

For this scenario, the volume to be infused is 100 mL, the drop factor is 60 gtt/mL, and the time is 60 minutes.

Plugging in the numbers: (100 mL × 60 gtt/mL) / 60 min = 6000 gtt / 60 min = 100 gtt/min.

Therefore, the nurse should set the IV flow rate to deliver 100 drops per minute.

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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 assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?

Correct Answer is A

Explanation

Correct Answer is ["100"]

Explanation

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