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?

will use a skin sealant before I apply the bag."

will use moisturizing soap to clean around the stoma before applying the bag."

will cut the wafer opening one-fourth of an inch larger than the stoma

1 will need to empty the bag every 4 to 6 hours."

Answer and Explanation

The Correct Answer is A

Choice A Reason:

"I will use a skin sealant before I apply the bag." This statement is appropriate. Using a skin sealant before applying the ostomy bag helps protect the skin around the stoma, creating a barrier against irritation and potential leaks from the stool. It demonstrates the client's understanding of preventive measures to maintain skin integrity.

Choice B Reason:

"I will use moisturizing soap to clean around the stoma before applying the bag." This statement is inappropriate. While keeping the area around the stoma clean is important, using moisturizing soap might not be recommended as it can leave residue and interfere with the adhesive properties of the bag. Typically, mild soap and water are recommended for cleansing.

Choice C Reason:

"I will cut the wafer opening one-fourth of an inch larger than the stoma." This statement is incorrect. Cutting the wafer opening one-fourth of an inch larger than the stoma might result in an excessively large opening, potentially leading to leaks or irritation. The ideal size is generally recommended to be as close to the stoma size as possible without causing pressure on the stoma.

Choice D Reason:

"I will need to empty the bag every 4 to 6 hours." This statement is incorrect. While regular emptying of the ostomy bag is necessary, the frequency can vary based on individual needs and stoma output. Some individuals might need to empty it more frequently or less often, depending on their stool output and comfort level.

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Correct Answer is C

Explanation

Choice A Reason:

Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms described in the scenario are more indicative of localized inflammation rather than nerve-related issues.

Choice B Reason:

Infection is incorrect. Infection at the insertion site can manifest with redness, warmth, tenderness, and possibly purulent drainage. While infection is a potential complication of IV therapy, the symptoms described might indicate a different issue.

Choice C Reason:

Infiltration is correct. Infiltration occurs when the IV fluid leaks into the surrounding tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid accumulating in the tissue instead of going into the vein. These symptoms align with the description provided.

Choice D Reason:

Phlebitis is incorrect. Phlebitis is the inflammation of a vein, typically presenting with redness, warmth, and tenderness along the vein's path.

A. “I’m going to take your heart rate." B. "I need to give you diphenhydramine." C. "Are you having difficulty breathing?" D. "Do you have any allergies to medications?"

Correct Answer is C

Explanation

Choice A Reason:
“I'm going to take your heart rate”. This statement is incorrect. Monitoring vital signs like heart rate is essential in assessing a client's condition. However, in this scenario, the client's report of hives, itching, and a potential allergic reaction is more indicative of an immediate concern for anaphylaxis. While monitoring heart rate is relevant, assessing for signs of anaphylaxis, especially difficulty breathing, takes precedence due to the urgency of potential respiratory distress.
Choice B Reason:
"I need to give you diphenhydramine". This statement is incorrect, administering an antihistamine like diphenhydramine can help alleviate allergic symptoms, including itching and hives. However, confirming the severity of the reaction and ensuring there are no life-threatening symptoms such as breathing difficulties is the immediate priority before administering any medication.
Choice C Reason:
"Are you having difficulty breathing?" This statement is correct. This question directly assesses the client's respiratory status, a crucial indicator of anaphylaxis. If the client is experiencing difficulty breathing, it indicates a severe allergic reaction that requires immediate intervention and emergency medical attention. Recognizing and addressing potential respiratory distress is of utmost importance in managing an allergic reaction to medication.
Choice D Reason:
"Do you have any allergies to medications? This statement is incorrect. Understanding the client's medical history, including allergies, is crucial. However, in this acute situation where the client is already experiencing symptoms of a potential allergic reaction shortly after receiving penicillin, addressing the current symptoms and assessing for signs of anaphylaxis is the most immediate concern.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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