A nurse is reinforcing teaching about lleostomy care with a client. The nurse should recognize which of the following statements by the client Indicates a need for further teaching?
"I will use caution when eating high fiber foods."
"I will empty my pouch when it becomes one third full."
"I will be certain to take enteric-coated medications."
"I will change my entire pouch system at least weekly."
The Correct Answer is C
A. "I will use caution when eating high fiber foods." Clients with an ileostomy should be cautious with high-fiber foods as they can cause blockages.
B. "I will empty my pouch when it becomes one third full."
This statement is correct. Regularly emptying the pouch prevents it from becoming too heavy and ensures comfort for the client.
C. "I will be certain to take enteric-coated medications."This statement indicates a need for further teaching. Enteric-coated medications are designed to dissolve in the intestine, but with an ileostomy, the medication may pass through the digestive system too quickly to be absorbed effectively. Clients should be advised to consult their healthcare provider about medication forms, as liquid or non-enteric-coated medications may be more appropriate.
D. "I will change my entire pouch system at least weekly."
This statement is correct. Changing the pouch system regularly helps maintain hygiene and prevents skin irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Monitor the client for manifestations of fluid overload: This action is not specifically related to C. difficile infection. Monitoring for fluid overload might be necessary in other situations, but it is not the appropriate action for this scenario.
B. Use alcohol hand sanitizer following client care: While alcohol-based hand sanitizers are effective against many pathogens, they are not effective against C. difficile spores. Washing hands with soap and water is necessary to remove the spores.
C. Disinfect equipment with bleach solution. This is the correct answer. Clostridium difficile (C. difficile) spores are resistant to many disinfectants, but they are killed by bleach. Therefore, equipment and surfaces should be cleaned with a bleach solution to prevent the spread of the infection.
D. Implement neutropenia isolation: Neutropenia isolation is a precautionary measure taken when a person has a low count of neutrophils, a type of white blood cell. This option is not directly related to C. difficile infection.
Correct Answer is C
Explanation
A. Diabetes mellitus
Diabetes mellitus can cause easy bruising and slow wound healing, but it is not typically associated with frequent nosebleeds.
B. Hepatitis A
Hepatitis A primarily affects the liver and does not cause frequent bruising and nosebleeds.
C. Cirrhosis
Cirrhosis, which is scarring of the liver tissue due to long-term liver damage, can lead to impaired liver function. One consequence of cirrhosis is decreased production of clotting factors, which can result in easy bruising. Additionally, the enlarged spleen in cirrhosis can lead to thrombocytopenia (low platelet count), contributing to bleeding tendencies, including nosebleeds. Cirrhosis is the most likely condition given the symptoms described.
D. Cholecystitis
Cholecystitis is inflammation of the gallbladder and is not directly associated with frequent bruising and nosebleeds.
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