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:
Chicken breast is a source of protein and does contain iron, but it is not the richest source among the options provided. Typically, poultry has less iron than red meat, and the iron present is non-heme iron, which is not absorbed as efficiently as heme iron found in red meats.
Choice B Reason:
Ground beef is a significant source of heme iron, which is more readily absorbed by the body compared to non-heme iron found in plant-based sources1. For individuals with iron-deficiency anemia, consuming heme iron sources like ground beef can be beneficial in improving iron levels.
Choice C Reason:
Pork roast contains iron, but it has a lower iron content compared to ground beef. While pork is a red meat and does provide heme iron, the concentration of iron in pork is generally less than that found in beef.
Choice D Reason:
Canned tuna does offer iron, but it is not as high in iron as ground beef. Fish contains non-heme iron, which, similar to chicken, is not absorbed as efficiently as the heme iron found in red meat.
Correct Answer is D
Explanation
Choice A Reason:
This statement is based on outdated information. Modern pacemakers are designed to withstand interference from microwave ovens, so it is not necessary to avoid them.
Choice B Reason:
Patients with pacemakers should be cautious about MRI scans because they can interfere with the device. However, many modern pacemakers are MRI-compatible, and a patient may undergo an MRI scan under specific conditions and with appropriate medical supervision.
Choice C Reason:
Traveling by plane is generally safe for individuals with pacemakers. Airport security detectors may detect the metal in the pacemaker, but they won't damage it. It's recommended to carry a pacemaker identification card when traveling.
Choice D Reason:
Holding a cell phone against the ear on the opposite side of the pacemaker is a recommended precaution to avoid potential electromagnetic interference. Although the risk is minimal, it is a simple measure to ensure the pacemaker functions properly.
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