A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching?
"I will use moisturizing soap to clean around the stoma before applying the bag."
"I will cut the wafer opening one-fourth of an inch larger than the stoma."
"I will use a skin sealant before I apply the bag."
"I will need to empty the bag every 4 to 6 hours."
The Correct Answer is C
Choice A Reason:
Using moisturizing soap to clean around the stoma is not recommended. Moisturizers can leave a residue that interferes with the adhesive of the ostomy appliance, leading to poor seal and potential leakage. Instead, the area should be cleaned with mild soap and water, and thoroughly dried.
Choice B Reason:
Cutting the wafer opening one-fourth of an inch larger than the stoma is incorrect. The wafer should be cut to fit snugly around the stoma to prevent skin irritation and ensure a secure seal. A gap that is too large can allow output to contact the skin, which can cause irritation and breakdown.
Choice C Reason:
Using a skin sealant before applying the bag is a correct practice. A skin sealant can protect the skin around the stoma from irritation caused by the stoma output. It also helps to create a better seal between the skin and the ostomy appliance, which can prevent leakage.
Choice D Reason:
The frequency of emptying the ileostomy bag can vary based on individual output and the consistency of the stool. While it may be necessary to empty the bag every 4 to 6 hours, this statement alone does not indicate a full understanding of ileostomy care. It's important to empty the bag when it's one-third to one-half full to prevent leakage and maintain comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
A backboard is not typically required at the bedside for a client with a seizure disorder. It is primarily used in situations where spinal immobilization is necessary, such as after a traumatic injury.
Choice B Reason:
Suction equipment is essential for a client with a seizure disorder. During or after a seizure, the client may experience difficulties with secretions or vomit, which can lead to aspiration. Suctioning helps to clear the airway and prevent aspiration pneumonia.
Choice C Reason:
Wrist restraints are not recommended for clients with seizures because they can cause injury if the client has a seizure. Instead, the focus should be on preventing falls and protecting the head during a seizure.
Choice D Reason:
Padded tongue blades are not advised and should never be used in a client with a seizure disorder. There is a risk of causing oral injury or choking if the client bites down on the tongue blade during a seizure.
Correct Answer is B
Explanation
Choice A Reason:
The recommendation for testicular self-exams is to perform them monthly, not every 6 months. Regular monthly exams are crucial for early detection of any changes. Testicular self-exams are recommended monthly because testicular cancer can develop rapidly, and early detection is key. Performing the exam every 6 months would reduce the chances of catching changes early.
Choice B Reason:Performing a breast self-examination (BSE) at the right time in the menstrual cycle is crucial for detecting changes accurately. Throughout the menstrual cycle, hormonal fluctuations can cause temporary swelling, tenderness, and lumpiness in breast tissue. However, these changes subside after menstruation, making it easier to identify abnormalities. The optimal time for a BSE is about a week after menstruation, when estrogen and progesterone levels are lower, reducing breast tenderness and swelling. Conducting the exam at the same time each month provides consistency, making it easier to notice any unusual lumps or changes. For postmenopausal women, choosing a specific date each month for a self-exam is recommended. While BSEs do not replace mammograms, they help individuals become familiar with their normal breast texture, aiding in early detection of potential concerns.
Choice C Reason:
The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommend an annual flu vaccination due to the frequent mutations of the influenza virus. Each year, new dominant strains emerge, requiring updates to the vaccine composition to ensure effective protection. Additionally, immunity from the flu vaccine declines over 6 to 12 months, making annual vaccination necessary to maintain adequate protection. This is particularly important for vulnerable populations, such as young children, older adults, pregnant women, and individuals with chronic conditions, who are at higher risk for severe flu complications.
Choice D Reason:
The hepatitis B vaccine schedule does not include yearly vaccinations. The standard vaccination schedule includes three doses over six months. However, there is no current search result available to provide the exact schedule. The hepatitis B vaccine provides long-term protection after the initial series of shots. Annual vaccinations are not required or recommended for hepatitis B, unlike the flu shot.
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