A nurse is teaching a client who has an ileostomy about the care of their stoma site. Which of the following statements made by the client indicates the teaching was effective?

"I should clean my stoma with moisturizing soaр."

"I should expect my stoma to be blistered."

"I should cut my pouch opening 1/8 inch larger than my stoma."

"I should change my stoma pouch 30 minutes after meals."

Answer and Explanation

The Correct Answer is C

Rationale:
A. "I should clean my stoma with moisturizing soap.": Moisturizing soaps can leave a residue that interferes with the adhesive seal of the ostomy pouch. The stoma and surrounding skin should be cleaned gently with mild, non-moisturizing soap and water to maintain skin integrity and pouch adhesion.

B. "I should expect my stoma to be blistered.": A healthy stoma should appear pink to red and moist. Blistering indicates trauma, irritation, or infection, which requires assessment and intervention, so this expectation is incorrect.

C. "I should cut my pouch opening 1/8 inch larger than my stoma.": Proper pouch sizing ensures a secure fit around the stoma while protecting the surrounding skin from effluent. Cutting the opening slightly larger than the stoma prevents pressure and irritation.

D. "I should change my stoma pouch 30 minutes after meals.": Ostomy pouch changes should be scheduled when effluent is minimal, typically every 3–7 days or when the pouch is leaking. Timing changes specifically after meals is unnecessary.

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Correct Answer is A

Explanation

Rationale:
A. Sore throat: A sore throat can indicate agranulocytosis, a potentially life-threatening adverse effect of clozapine. Prompt monitoring of WBC counts and reporting symptoms such as fever or sore throat is essential to prevent serious infection.

B. Tinnitus: Tinnitus is not a common or severe adverse effect of clozapine. While it may be bothersome, it does not require immediate reporting to the provider in the context of clozapine therapy.

C. Rhinitis: Mild nasal congestion or rhinitis can occur with clozapine use but is generally not dangerous or indicative of a serious complication. Monitoring is routine, but urgent reporting is not required.

D. Headache: Headaches are a common, nonspecific side effect and do not typically indicate a life-threatening reaction. Routine assessment and symptom management are appropriate.

A. Instruct the parent to give the infant water every 3 hr between feedings. B. Recommend the parent mix the milk with rice cereal for feedings. C. Instruct the parent to give 5 mcg of vitamin D daily. D. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age.

Correct Answer is D

Explanation

Rationale:
A. Instruct the parent to give the infant water every 3 hr between feedings: Giving water to infants under 6 months can displace nutrient intake and increase the risk of hyponatremia. Breast milk or formula should remain the exclusive source of nutrition at this age.

B. Recommend the parent mix the milk with rice cereal for feedings: Introducing rice cereal at 3 months is not developmentally appropriate and can increase the risk of choking. Cow’s milk lacks the proper nutrient balance, and adding cereal does not correct these deficiencies.

C. Instruct the parent to give 5 mcg of vitamin D daily: While vitamin D supplementation is important for infants, the concern in this scenario is the use of cow’s milk, not vitamin D deficiency. Breastfed infants should receive supplementation, but formula-fed infants typically get adequate vitamin D through fortified formula.

D. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age: Cow’s milk should not be introduced before 12 months because it lacks iron, vitamin E, and essential fatty acids, and can cause gastrointestinal irritation and occult blood loss.

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A nurse is teaching a client who has an ileostomy about the care of their stoma site. Which of the following statements made by the client indicates the teaching was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking clozapine. For which of the following adverse effects should the nurse monitor and report to the provider?

Correct Answer is A

Explanation

A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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