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 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.

A. Keep the head of the bed elevated at 15 degrees. B. Place enough formula in the feeding bag to last for 8 hr of continuous feeding C. Flush the tube with 30 ml of water every 4 hr. D. Change the feeding bag and tubing every 72 hr.

Correct Answer is C

Explanation

A. Keep the head of the bed elevated at 15 degrees.

This is not sufficient for preventing aspiration and ensuring proper digestion. The head of the bed should be elevated at least 30 degrees to reduce the risk of aspiration and promote better digestion of enteral feedings.

B. Place enough formula in the feeding bag to last for 8 hr of continuous feeding: It is recommended to change the feeding formula and bag every 24 hours. Placing formula for an extended period can increase the risk of bacterial growth.

C. Flush the tube with 30 ml of water every 4 hr: Regular flushing of the tube helps maintain patency, prevents clogging, and ensures proper hydration. Flushing every 4 hours is a standard practice for continuous feeding.

D. Change the feeding bag and tubing every 72 hr: Feeding bags and tubing should be changed more frequently, typically every 24 hours, to reduce the risk of infection.

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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 in a clinic is caring for a client who has alcohol use disorder. The client reports frequent bruising and nosebleeds. Which of the following conditions should the nurse suspect?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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