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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Blood glucose 150 mg/dL:
This blood glucose level is slightly elevated but not significantly concerning on its own. It may be related to stress or other factors. In the context of acute gastroenteritis, it might be secondary to dehydration, but it is not an immediate priority unless the client is diabetic.

B. Potassium 2.5 mEq/L:
This is the correct answer. Low potassium levels (hypokalemia) are a severe concern, especially in the context of acute gastroenteritis where there can be significant losses through vomiting and diarrhea. Hypokalemia can lead to cardiac arrhythmias and needs urgent correction.

C. Weight loss of 3% of total body weight:
While weight loss is an important parameter, a 3% weight loss is usually not an immediate concern. In cases of acute gastroenteritis, rapid weight loss might indicate severe dehydration, but this choice is not as urgent as addressing a severe electrolyte imbalance like hypokalemia.

D. Urine specific gravity 1.035:
This specific gravity indicates concentrated urine, which could be due to dehydration. While this finding is important and indicates the need for rehydration, it is not as urgent as correcting a critically low potassium level.

A. Place the client in a supine position. B. Withdraw the tube if the client gags during insertion. C. Measure the tube for insertion from the tip of the nose to the umbilicus. D. Instruct the client to place his chin to his chest and swallow.

Correct Answer is D

Explanation

A. Place the client in a supine position.
Placing the client in a high Fowler's position (sitting upright) is the appropriate position for inserting a nasogastric tube. This position helps facilitate the passage of the tube through the nasopharynx and into the esophagus and stomach.

B. Withdraw the tube if the client gags during insertion.
Gagging during insertion is a normal response. Advancing the tube slowly and having the client swallow can help pass the tube through the nasopharynx.

C. Measure the tube for insertion from the tip of the nose to the umbilicus.
The correct measurement for insertion is from the tip of the nose to the earlobe and then down to the xiphoid process (not the umbilicus).

D. Instruct the client to place his chin to his chest and swallow.
This instruction is appropriate. Asking the client to flex their head slightly forward and swallow helps guide the tube into the esophagus.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

Correct Answer is B

Explanation

The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following Interventions should the nurse take when inserting the nasogastric tube?

Correct Answer is D

Explanation

A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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