A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?
I will irrigate the colostomy every day.
I will notify my doctor if the stoma starts to look purple.
I will no longer be able to eat nuts.
I should expect my stool to be formed.
The Correct Answer is B
I will notify my doctor if the stoma starts to look purple
The comment by the client indicating an understanding of the teaching is option B: "I will notify my doctor if the stoma starts to look purple."
I will irrigate the colostomy every day in (option A) is incorrect. Colostomy irrigation is not necessary for all clients with an ascending colostomy. It is important to individualize the teaching based on the client's specific needs and healthcare provider's instructions. Routine colostomy irrigation may not be required, and the client should follow the healthcare provider's guidance regarding colostomy care.
I will no longer be able to eat nuts in (option C) is incorrect. There are generally no dietary restrictions for clients with an ascending colostomy, unless otherwise advised by their healthcare provider. It is important to provide accurate information about dietary considerations, which may vary based on individual circumstances and healthcare provider recommendations.
I should expect my stool to be formed in (option D) is incorrect. With an ascending colostomy, the stool is typically liquid or semi-liquid as it comes from the ascending colon, which is higher in the gastrointestinal tract. The stool is not expected to be formed. It is important for the client to have appropriate expectations regarding stool consistency to manage their colostomy effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"My baby will receive the rotavirus immunization orally." - This statement is correct. The rotavirus vaccine is administered orally, typically as drops or as an oral suspension. It is important for the guardian to follow the specific instructions provided by the healthcare provider for the administration of the rotavirus vaccine.
"I should not feed my baby anything for 2 hours prior to an immunization." - This statement is incorrect. It is not necessary to withhold feeding prior to immunizations. In fact, it is generally recommended to feed the baby before the immunization to help provide comfort during the procedure.
"My baby will receive three doses of the meningococcal immunization before kindergarten." - This statement is incorrect. The number of doses and the schedule for each immunization may vary. The guardian should consult with the healthcare provider or refer to the immunization schedule for specific recommendations regarding meningococcal immunization.
"I should expect my baby to have a high fever for 24 hours after an immunization." - This statement is not entirely accurate. While it is common for infants to experience mild side effects such as a low-grade fever after immunizations, a high fever is less common. The guardian should be aware of the potential side effects and contact the healthcare provider if they have concerns about their baby's reaction to the immunization.
Correct Answer is ["B","C"]
Explanation
The client received the prescribed antibiotic every 8 hours: This is important information as it relates to the client's medication administration and treatment plan. It allows the incoming nurse to be aware of the medication schedule and ensure continuity of care.
The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client.
The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.
While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.
In summary, the nurse should include information that is pertinent to the client's immediate care needs and current condition. This includes medication administration, pain management preferences, changes in condition, or any relevant information that may impact the client's care plan.
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